General Question

kheredia's avatar

Have any of you ever gotten screwed by your medical insurance? Were you able to do anything about it?

Asked by kheredia (5558points) June 8th, 2009

My dad has been through several surgeries in the past few months and last night he had to be taken to Emergency because he got an infection from the last operation he had. Somehow, the insurance no longer wants to cover his stay at the hospital. How lame is that?? Isn’t that what they get paid for?? What’s the use of giving them money every month if they’re not going to help you when you need it. It’s not like we all have an extra 10k in the bank just in case we have to stay in the hospital for a week. At least not if you have insurance. You would think you wouldn’t have to worry about that stuff.

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13 Answers

Darwin's avatar

Our insurance insisted that my daughter’s hospital stay when she was 10 days old was due to a pre-existing condition. They demanded to know what doctors she had seen for this condition during the previous 12 months (none – it didn’t start until 10 days after she was born and actually wasn’t correctly diagnosed until she was 2 1/2 years old). They refused to pay because I couldn’t tell them who the doctor(s) was/were. I sent them a letter copied to my attorney. They paid.

Question – does his insurance require someone to call them within 24 hours of an emergency admission? Ours does and won’t pay unless you have a really good reason for not calling.

kevbo's avatar

See here to read about some of your options.

chyna's avatar

Is it regular private pay insurance or Medicare?

kheredia's avatar

I believe it’s medicare, but not sure.

Darwin's avatar

You need to find out why the insurance says it will not pay before you can begin to address the problem.

kheredia's avatar

They’ve already covered his hospital stay before. I’m not sure why they don’t want to cover it this time around. Are they suppose to have a limit to how many days they can cover or something like that? I don’t know too much about medical insurance.

chyna's avatar

If it is Medicare, the hospital can refuse to pay it, but if your father wasn’t told prior to leaving, he is not responsible for the bill. In fact, Medicare will send him an EOB, explanation of benefits, that will tell him he is not responsible for the bill. The hospital can not demand payment from your dad if this is the case.

chyna's avatar

An emergency room visit should be paid and not included in how many days your father has used.
Did they admit him to the hospital or just treat on an emergency basis?

kheredia's avatar

He was admitted this morning. We don’t know how long he’ll have to stay there.

Darwin's avatar

Sometimes it is because the doctor in the Emergency Room doesn’t actually work for the hospital but for a doctor-staffing service. Sometimes it is because someone checked the wrong box on the form or forgot to check the right one. Sometimes it is an error. Sometimes it is called something Medicare does not cover, although it could also be accurately described by another term, that Medicare does cover. And sometimes Medicare decides something is an unnecessary procedure and does not cover it.

Here is a general listing of what Medicare does not cover.

You need to ask Medicare why it isn’t covering this hospital stay. Only then can you work with the hospital to figure out how to get the bill covered.

PandoraBoxx's avatar

The main reasons why claims don’t get paid are (not in any particular order):
1) The insurance plan requires prior authorization for treatment, and the patient didn’t get it.
2) The treatment sought is not covered by the insurance plan (READ YOUR CERTIFICATE OF COVERAGE TO FIND OUT WHAT YOUR PLAN COVERS OR IF THERE ARE LIMITS)
3) The provider coded the procedure incorrectly
4) The condition is a pre-existing condition, and the policy may not cover pre-existing conditions for a certain time period.

If you are covered by a group plan through work, the insurance that you are offered is what your employer has selected for your coverage options. Different plans have different limits. The most important thing you can do is read and understand your certificate of coverage BEFORE you have a medical emergency. Having insurance does not mean “get everything for free.”

If you have a complaint that you can’t get resolved, there is a Grievance and Appeals process. This can be found with the Explanation of Benefits your insurance company mails you to tell you how they paid your claim, or if they didn’t pay the claim, why they didn’t. Many people throw these away; they are very important to keep and read.

chyna's avatar

If it was within 30 days of his last stay, and if it is Medicare, they will most likely pay it. Also, he won’t be responsible for his deductible again if it was within 30 days.

kheredia's avatar

Thank you all very much. I’ll be looking into this more in detail and hopefully get this taken care of.

@Chyna, He was just released from his previous surgery a couple of weeks ago so hopefully you are right and they’ll pay it. Thank you for all your help.

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