Need advice/help dealing with insurance company denial

[Retired Finally]

My daughter and her husband, who live in Nashville, recently had a large provider bill denied payment by their insurance carrier. This was after a pre-certification approval by the carrier and their going thru the companies appeals process. I have suggested that they contact their state Department of Insurance and perhaps the Tenn Attorney Generals Office.

In my experience a really tough attorney should be retained to work on their behalf. Do any of you have any suggestions about other avenues of approach and most importantly, do any of you have know some names of real aggressive attorneys in the Nashville area that specialize in this type of issue that you can share?

Many thanks for your input!

Retired Finally

[bluemarlin08]

I live and work in the area and have some experience relating to this issue. Usually a denial to pay is related to a claim there is a pre existing condition not disclosed on the application. If your case is a slam dunk, which they rarely are, you can get a qualified attorney to take a look and may take the case, but all will require a retainer and the process could drag on for ever. If you would like to PM me I can direct you to an attorney that can make a recommendation.

[stjoe56]

I live and work in the area and have some experience relating to this issue. Usually a denial to pay is related to a claim there is a pre existing condition not disclosed on the application.

I semi-disagree. I had a pre-existing condition of high-blood pressure which was disclosed. Thereafter the insurance denied every major claim saying it was caused by high-blood pressure. This included a removal of a gall bladder and back surgery. The letter the neurosurgeon wrote the insurance company when it denied surely ranks in the levels of contempt and sneering. I remember words along the lines of "the most idiotic reason for denial he has ever heard."

I found the easiest way to get an insurance company to pay is to write a state insurance commissioner. After that the insurance company always paid the claim.

SJ

[bluemarlin08]

Everything is fact dependent, glad you got your issues settled to your advantage. Some companies, such as Blue Cross in Tennessee, has a pre existing condition period exclusion that states if you have been treated for an illness or injury in the past 12 months then treated for the same condition in the next 12 months they can deny the claim. This clause seems rather cloudy when dealing with someone being treated for HBP, many problems could "potentially" be denied because of the HBP.

[deanbrew]

Uggh, I hate this aspect of health insurance. My local BCBS insurance denied payment for my annual checkup last year (first year on a new policy), which is supposed to be fully covered as preventative care. They denied payment due to the pre-existing condition clause because the doctor and I discussed a minor condition for which I am not receiving any treatment nor taking any medication. I went round and round with the insurance company and said of course we discuss my health and various (minor) maladies during my annual checkup - that's what it's about!! They said it all comes down to the codes the doctor's office puts on the submission, and since one code was the same as the year before, they would deny payment. Thankfully, it wasn't a huge amount of money, but the logic makes no sense and the bureaucratic BS is maddening. You feel like you're trapped in an alternate universe.

[john94549]

When I read posts like this, I am so, so glad I have Kaiser Senior Advantage (their Medicare Advantage program).