Life & Health Insurance/Health insurance coverage
QUESTION: I purchase individual health insurance ($2500 deductible) form Cigna when I lost my job. I know I need annual ultra sound and mammogram so I asked if these fall under preventative women wellness and if these will be counted as deductible. I even explain if these will be counted as deductible, I will have to choose a different plan. I asked this question 3 times at different points - over the phone with an agent when I apply, twice with the benefit agent after phone enrollment. All 3 times I was told that ultra sound and mammogram are considered women wellness and are covered 100% and not counted into deductible. After my clinic visit for ultra sound and mammogram, I received a $2000 bill. When I call Cigna, the agent said it should not count as deductible and suggest me to call the clinic to correct the billing code. Long story short, I was bouncing back and forth between the clinic and Cigna. I finally decide to appeal with Cigna but Cigna decline my appeal yet never send any decision letter to me. I found out my appeal was denied because I received letter and phone call from collection agency.
What option do I have at this point? Is there any channel that I can complain thru and get help with this issue?
Thanks so much for your time and help!
ANSWER: Hello Amy:
I will look into what other options you have in Florida regarding the $2000 medical bill, and will respond to you later today. As a broker licensed in Arizona and Rhode Island, I am not familiar with Florida insurance rules and regulations, but should be able to point you in the right direction with specific recommendations to resolve this issue.
That said, I do have a question for you, and will wait for your response before looking into this matter further. In your message you say... "I know I need annual ultra sound and mammogram..." Did a doctor or medical professional recommend that you have these procedures performed each year due to a pre-existing condition you had, or have, before applying with Cigna?
Thank you Amy, and I await your response.
---------- FOLLOW-UP ----------
QUESTION: Hi Mike,
Thank you for your quick respond.
To answer your question, yes, I was advised by OBGYN to have annual ultra sound to monitor the size of the cyst and mammogram because of my age.
I don't remember all questions asked during application with Cigna, but I am sure I've provided honest answers.
From what you have told me it sounds like the ultrasound and mammogram procedures are part of an ongoing treatment plan prescribed by your doctor in response to a pre-existing condition, therefore not covered under preventive services benefits, and would be subject to your annual deductible. Long story short I think they billed you correctly.
This does not mean there is nothing else you can do other than pay the full bill. I recommend contacting the Florida Department of Insurance and file a complaint. Here is a direct link to do this, http://www.doh.state.fl.us/mqa/enforcement/enforce_csu.html
Your situation is one of the most common complaints in health insurance unfortunately, and your state Department of Insurance will assist you in resolving this issue. As is sometimes the case when purchasing health insurance, the seller does not make clear the restrictions involved in coverage, when the deductible applies, etc. And sometimes the purchaser of the policy simply does not understand, or misinterprets, what they have been told by the insurance company or agent. I doubt very much that an employee or agent of Cigna intentionally misled you, they are a fine and respected insurer, but obviously they did a poor job in explaining exactly how and when the deductible applies. I also know that you did not mislead Cigna, you come across as a very trustworthy individual. Possibly though you did not understand correctly what Cigna may have told you, we are all human and do make mistakes.
My guess is that some sort of agreement will occur between you and Cigna in your favor, but first you will need to have the Florida Department of Insurance step in and help you.
Please let me know how things turn out, and if I may be of further assistance.