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About R. Gene Ramsay
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I can answer questions from people regarding health, life, and supplemental insurance. I can also answer certain annuity questions, long-term care, medicare, vision, dental, group products, individual products, and certain carriers. Another area would be general discussion on an individual basis to determine need and help individuals make the right decisions for them. I can also field questions from other insurance providers about carriers I represent so we can do some business together and I am also willing to offer my thoughts on certain issues they may be having with clients/customers, etc.

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You are here: Experts > Money > Personal Insurance > Life & Health Insurance > Insurance company refusing to pay although patient was covered

Life & Health Insurance - Insurance company refusing to pay although patient was covered

Expert: R. Gene Ramsay - 10/29/2009

Question
My fiance went to the emergency room a few weeks ago. A couple of weeks after that she was laid off from her job, which ended her insurance comany. She was insured until October 1 2009, and her emergency room visit was in September.

The claim was submitted by the hospital and received by her insurance company on September 22. Due to their own slow pace, they didn't review her claim until October, by which point she was no longer insured by them, so they denied the claim.

She's been fighting with them and with the hospital with no luck. The hospital is being told by the insurance company that they should bill the patient, and when she calls the insurance company they basically tell her to go to hell. There seems to be no "higher up" people to speak to, and since she's no longer a patient they have no interest in bothering with her.

Is there any way we can win this fight? My fiance looked into lawyers but it seems like they'll as much, if not more, than the emergency room bill itself.

Thanks in advance

Answer
Michael,

I am sorry to hear that your fiancee' needed emergency care. That is never fun and I hope she is doing better.

First things first, it might help if I knew what carrier she had and what the plan design was like. This info may be tough to get to me, but usually am employer gives the employee a booklet from the company when they sign on that gives them a full understanding of what the policy does and does not do, etc. My other first question deals with COBRA. She gets a certain number of days after the fact that company must offer her COBRA coverage to fill in the gap until she can find other insurance. Did you ever get that offer? If not, you need to be on the employer for that piece of info.

Now, you say she was technically covered through October 1, 2009 (or the last day of September. Normally, an insurance company honors all claims filed while the insured was actually under the coverage. In your case, it would depend on the date your fiancee' would have had an insurable situation (when she was treated). If that date lands well within September, it should not matter when they reviewed the claim or even received it. It's based, usually, on the time of loss. That may be your biggest point in this and it may also be stipulated in the insurance company's booklet the employees should get from the employer.

Keep on the communications and document everything. Every person you talk to, get a name. Every day you call, put down the date and the time and all people you spoke with. Quote them the best you can as to what the person on the line says. That will be key as you keep this up. Don't hedge the facts with your emotions into it. Be factual and quote the situations exactly as they happened. This gives you all the ammo you will need as you continue to get this resolved as you will continue to get the runaround until someone finally gets you to someone who can help. The hospital billing department is your best bet. Those folks deal directly with the billing and can help guide you, if you will let them. Try not to get defensive or come at them with "what they need to do". But the key is to call every day and find that one person who you can call to help. Shoot, if it were me I would be down there in person with my bills and my documentation until they got tired of seeing me and I would keep on going...if I know I have a right to continue to be there. Now, if you find that your fiancee's policy would not have covered this situation regardless realize that that would be in writing and you would really have no recourse other than to then deal with the insurance company directly. Always remember, while the insurance company has the money to pay it, if they don't have to they won't. They are in the business to keep those funds unless they just have to let them go. I am also not certain what state you are in, but different states handle all this differently. From a legal standpoint, arbitration (cheaper option) can be called on to help. If you have to pursue the lawyer option, find one who will look at all the info and see if they would do a pro bono set up with you (if they get any extra funds other than your bill paid, they get a percentage or all of it). If they know they can win it, then you are out no money in normal situations. You might have a retainer fee, but that is usually not much.

I hope any or all of this helps you. I am not in the legal field and I do not work as closely with health insurance companies other than to educate and communicate what the policies can and can not do.

Contact me back with any follow ups you might need and I will see what I can do for you.

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