Daughter had surgery a year a go and the insurance company is sayign they are not paying their half?

Question

Our daughter had eye surgery a year a go on her eye lid. The lid was covering her eye in a way which could have the brain shut the eye down and she would be come blind in that eye. She has been seeing a doc since she was 2 months old and when she turned 2 her doctor said it was at teh point where it was covering the eye and she could start to have some eye sight issues. We asked our insurance company and the doctor numerous times if this would be a cosmetic surgery and the doctor said it would not be due to the fact her vision was in jeopardy. Now the insurance company is saying that after reviewing files and pictures that they are denying the claim. This was a year ago!! we were sent a 6,000 medical bill. My wife and took this surgery as a huge deal and did alot of research and asked alot of questions to aviod this. If you have any helpful info that might come in handy please let us no. Thank you

Answer 1

Normally there should have been a pre-determination done for a surgery like this.  Your doctor would (should) have sent photos of your daughter's eyelid and her medical chart for the insurer to review and give approval prior to the surgery.  I'm surprised that there was no written approval done in advance.

Your policy should describe your appeal rights with the insurer - I'd advise that you follow all the steps of appeal.

If your insurer denies all of your appeal levels, then (in most states) you would have a right to an independent medical board review of your daughter's case.  Your insurer and/or your state's Department of Insurance should be able to tell you how to proceed with this.  I think there is a similar procedure in most states, my state works as follows:  you have to exhaust the levels of appeal within your insurance company before having a right to the independent review.  The independent review is coordinated by the Department of Insurance - a board of physicians review the information that your daughter's physician presented to the insurance company, and make a ruling on whether or not the procedure should have been approved.  (Again, that's the way it works in my state - your state's Department of Insurance will be able to tell you how it works in yours.  Even if it doesn't work exactly like how it does here, there should be some type of similar procedure.)

Good luck.

Answer 2

sorry,  you should have got the pre-authorization in writing.

You can fight the ruling,  but it will be hard.

It would cost you more than $6000 to have alawyer fight it in court.

Answer 3

Insurance companies like to deny a lot of claims when they are first filed. Make sure you read the fine print of your policy about appeals and legal rights. I would advise that you should contact an attorney quick. If it doesnt work out you might contact the shriners they do alot with children. Also you might be able to negotiate a lower amount with the hospital.

Answer 4

mbrcatz1 is right.

Answer 5

Hi,First of all you just check your policy wether the policy cover the insurance of the very claim or not.If the claim covers than go to the company and shoot the claim first.If the company denied then go to the lawyer and try to resolve the issue with the ombudsment.No claim has been deny by the insurer if the claim is true and the period of the claim is covered.

Answer 6

okie dokie, right up my alley :) i work for a large insurance company in the appeals department oddly enough and i see things like this every day....

1) you have longer than six months to appeal something (another reader brought that up)

2) read your benefit booklet, and flip directly to the policy exclusions. you want to look for anything regarding: cosmetic surgery, elective surgery, vision coverage, medical necessity clause and experimental procedures.. read up on all that and see if your situation falls into any of that. if it does, it is not worth fighting, because it is in black and white. and i will tell you why.....

3) if you file an appeal through your insurance, and the procedure falls under one of the benefit exclusions, the issue is dead in the water. the next step, is to file an appeal through the state. at that point, an Independent Medical Review would be done, and a recommendation could be made that the insurance company pay the claim. additionally, if the company is found to be in violation of any laws, they will be fined. now, i will tell you.. in my experience, something like this (although to me it makes sense) in the insurance company's eyes, i bet it will either be considered: not medically necessary, experimental, or investigational...

it is not in your best interest to contact a lawyer, as it would simply cost more in retainer fees than the cost of the procedure...if all else fails, try to strike a deal with the billing provider. i hate to say it, but i do not think this is going to go in your favor :(

Answer 7

How long ago did they deny the claim?  You usually have six months from the denial, to appeal.

You need to appeal this claim.  

I'm not surprised this happened - the first people who review claims are pretty much low level, low paid people who deny out of hand if it looks like it might be a voluntary coverage.

My son was born with a severe tongue tie that interfered with his eating.  I had to get it clipped as a newborn, but the insurance denied twice before I got them to pay it, after appealing twice. (no, it wasn't a cosmetic dental procedure!! he needed to EAT!!).

You just need to appeal this . . . and mark your calendar, and stay on top of it.

Answer 8

1.) Did you get a predetermination for services? Normally, for a procedure that is possibly cosmetic, the doctor should provide pictures and records before performing this service to your insurance. If you get a predeterm, you may have a leg to stand on.

2.) Call your carrier and ask them how long you have to appeal and tell them you want to start the appeals process. They should be able to provide you with the necessary information to start.

3.) Please do not assume (as someone stated) a "low paid" and the bottom of the totem pole person can just deny a claim for your daughter. It does not work that way. When a claim comes in for POSSIBLY COSMETIC, the computer system is already setup to kick those claims out. It is then sent for review, in which they first look for a Predetermination (PD). If there is one on file already, then they are able to process and pay the claim.

If not, then it is rejected and the medical records are ordered from the doctor. Once received, the records are reviewed and then determined if it is medically necessary (MN). To you, the service may have been MN, but it may not meet medical criteria and therefore not MN with your insurance company.