Denial of Medical Coverage by the Insurance Company : When Fighting Back Needs More than a Simple Demand Letter
67The Request
When a reader emailed me recently with a request for tips about writing a demand letter to her mother's insurance company after the company denied a medical claim, I wrote back (naturally). When I was done, it dawned on me: I'd written a Hub.
Here it is.
The Response
Dear Susannah,
Having read my Hub on How to Write a Demand Letter, you asked for tips in writing a demand letter to the insurance company that denied your Mom's claim on the basis that she'd not mentioned a preexisting condition.
There's a problem.
I don't mind helping as I can, but this one is too tough for a demand letter. I know this from having had twelve years of experience as a commercial insurance underwriter--not insurance sales, but the guy who decided whether or not the company would insure the local strip mall, doctors, truckers, whatever.
If your Mom is to have a shot at beating the insurance company, she needs either:
A. A sharp contract attorney who understands instinctively how to whack 'em over the head when it comes to the loophole, or
B. A good rabble-rousing advocacy group like NOW (National Organization for Women), or any other organization capable of scaring the pants off the insurance company, or
C. A sharp reporter who has a shot at giving this denial of coverage national exposure, or
D. (Seriously) A Presidential candidate who can take up her cause more "sharply" than the reporter, or
E. All of the above.
What the insurance company will do the moment they see they're facing resistance to the denial of your Mom's claim is to pass the file to one of the company-employed lawyers in their Claims Dept., and the next response from them will be a tougher letter from that lawyer. The war will escalate from there until they decide it's going to be more expensive to fight your Mom than to pay up.
Pure and simple, that's how it's done.
Now, that sounds pretty nasty, and it is. But if y'all do decide to fight, then the questions become:
1. Are they lying about denying coverage when an applicant has asthma? It would likely take some heavy PI work to find out for sure, but they may or may not be telling the truth in the first place.
2. Even if that's true, a lawyer (depending on how sharp he or she is and the laws in your state) could decide there's a strong case for at least forcing the insurance to reimburse your Mom for every penny she paid them in premiums. After all, if there never was any contract (as they're claiming), then they never had any right to take her money. That might not add up to much, but at least it would be something.
3. There could be legal precedents (other cases) already decided by the Courts that would weigh in on your Mom's side.
And...I'm sure I'm missing something; there's always another angle if you dig deeply enough.
If this sounds overwhelming--sorry about that, but you deserve to understand that this a situation which, though it can perhaps be rectified, will likely require not just a simple little battle but an entire war.
Sincerely,
Ghost
vote upvote downshareprintflag
- Useful (5)
- Funny
- Awesome (4)
- Beautiful
- Interesting (6)
CommentsLoading...
I've thought of many angles to dispute a denied claim, but never a refund of all premiums paid since the insurance company claims the contract never existed. Love it!
Personally, I'm of the opinion that all health "insurance" CEOs and their sales reps could and should be prosecuted for fraud, and for racketeering under the RICO Act, because there's only one difference between health "insurance" and the "insurance" the Mob used to extort from business owners and such.
That one difference being "premiums" paid by business owners to the Mob actually kept bad things from happening to their livelihood as long as they kept paying, whereas the premiums paid to a health insurance company pretty much *guarantee* bad things will happen to one's livelihood (and life) *despite* continuing to pay. It's a license to steal, pure and simple.
vocalcoach: That is the general rule of thumb. When they decide up front to honor a claim, it's often just because coverage clearly did apply. But once a claim has been denied, then yes, it's all in the financial equation.
JamaGenee: Yeah, that was interesting about this one. Usually, they simply say, "Oh, you tried to defraud us, so no coverage! Boo hoo you!" But this time they actually used those words, that "the contract never existed". Seems like a fine way to hang them by their own petard, as it were.
I'm not 100% sure "all" would technically qualify as fraudsters--they well might--but I do know my personal definition of insurance has never been echoed by any other individual. Within my hearing, anyway. That definition is:
"Insurance is nothing more than man's attempt to duck his own karma."
Women included in the term "man's", of course.
I only carry insurance where the law will hurt me really badly if I don't--auto liability insurance, for example. But NOTHING else at presence. Nothing on Pam (which she rather resents, but it's not like we have the coin to pay for it anyway) or me medically, nothing on the house, and nothing in the way of physical damage on the vehicles.
Yes, I've used the medical industry (physicals for trucking, and a hernia repair in early '06) and I've wrecked a car (don't ask--it was utterly dumb driving, brain fart all the way). And I paid for all that, cash and carry all the way.
If I get a terminal illness that would cost fifty gazillion dollars to treat and I don't have fifty gazillion dollars on hand, so what? I die, and then I reincarnate. Big whoop.
I have seen this many times. Health insurance is about money not insurance. Just ask Florida's Gov. Rick "medical fraud" Scott. Good advice.
I hate their pre-existing condition clause. Sometimes you do not know you have the problem but it has been noted in your Dr. charts. I found out I had asthma 2 years after it was noted. The Dr just didn't think to mention it to me because I didn't need medicine for it yet.
When I did need it, the insurance co. said it was pre-existing, which it was but I didn't know it was until I asked my Dr. about it. I am thankful now that I don't have to worry about it. The disabled veterans insurance I have now will cover it because it was not pre-existing when he was in the service. I was only in 3rd grade then.
An aunt and uncle who married in the 1930s (with the Depression still fresh in their minds) somehow managed to raise 4 kids on what amounted to minimum wage in those days while squirreling away every penny they could toward medical bills they might incur in old age. Didn't believe in health insurance and assumed (correctly, as it turned out) one of them *might* become seriously ill before Medicare kicked in. Also correctly calculated that the interest accrued on that "medical nest age" would be more than enough to cover the costs of a serious illness.
I've often wondered why the same sort of plan isn't in use today, instead of us being pretty much forced, through our jobs, to hand over an obscene amount of money in premiums to health insurance companies who fight us tooth and nail not to give it back when we need it.
Fred, great timing on this hub, I just started my own battle with insurance regarding my wife's recent stroke. I have Medicare and a Private Insurance, and now discover this is a bad thing.
The bills have just now started flooding my mailbox. Her helicopter ride to the Trauma Center was slightly over $20,000. Medicare pays $00.00, Private Insurance pays $00.00. If you do the simple math, that leaves my share at $20,000. Now most everyone knows that in the case of stroke, the faster the treatment starts, the better the odds of recovery, thus the paramedics insisted on the helicopter ride because of our rural location. For this I thank them and the helicopter crew for a job well done. I got my wife of 48 years back in reasonably good condition.
A head scan to determine the extent and location of the brain damage cost $750. Medicare paid $32 and Private Insurance paid $00.
So as you can see, my battles with the insurance companies is just beginning. The irony of this is that if I were in this country illegally with no insurance, she would have received exactly the same care and my cost would have been $00. So having insurance that pays little or nothing is going to end up costing me a great deal out of pocket. My wife is worth whatever it costs, but that is not the point.
I may be writing a few letters myself and will be giving you a call for some advice.
You give wonderful advice, Ghost. Up and useful.
A wealth of information here, I am lucky that I have VA coverage and unlucky why I have it, nonetheless the first quarter of this year I got probably a 200,000 open heart surgery that has I not been in the VA coverage, I'd have zero coverage and if I did, it being number two open heart probably would have been preexisting and I'd be fertilizer under the sod or "dust in the wind" after a trip to a knock off "Hitler-oven" LOL [a little humor that is really not]. I have prior battle experience with a insurance company, that required an attorney and though it took 18 months and a suit of "Breech of contract" ended up well. I won't name the cupped hands as was part of the judges decision, in my favor.
I do realize that had it been a health issue that was deadly, someone else would have collected the money.
This is the only thought that obama might strike agreement in word with me, is coverage should be there for all humans, I just disagree with his method and plan, as illegals get coverage the working paying citizens are denied.
I'll shut up now, voted up! Blessings, dust
GNelson: I'm not up on Gov. Scott. Looks like it's time to do a bit of reading.
Becky: That's..."interesting", about the problem arising in part because your doctor didn't MENTION you had asthma. Pam's fibromyalgia was like that in the beginning. She and I knew she had it, but her South Dakota doc (in 1997 to early 1999) wouldn't admit it. Yet when we snagged her medical records on the way out of town, he'd noted, "...shows all the classical symptoms of fibromyalgia."
It wasn't as well publicized then, at least not in the rural states. We suspect the doc was simply AFRAID to come out openly with the diagnosis and stand by it.
JamaGenee: Exactly. Couldn't have said it better myself. Plus, of course, there's the "wastage" as the money cycles through the insurance company before it comes back out in the claims that are paid. Not as grossly ridiculous as government-operated boondogles (duh), but roughly 40% of every premium dollar ever paid stays with the company.
Mike: Ouch on the chopper cost (while, as you say, good on the job well done).
As you already know, you're more than welcome to call any time. Hard to say how much help I can be, but what little insight I can offer, I most certainly will.
BPop: Thanks. Voice of experience if nothing else.
50: That's a lot of information packed into that first paragraph, Dusty. Understood on the cupped hands; had an early auto insurance hassle (1968) with those folks myself.
Obama's stated desire to cover all humans does sound good in theory, but there are serious problems:
1. Obamacare as the law is written won't provide that coverage anyway.
2. The cost for those it does cover is not going to be cheap.
3. If we (meaning the People of these United States) are ever going to achieve universal coverage, it most certainly won't be through governmental action. Govt. is just not efficient enough, at least not without taking over our lives entirely.
And Life itself is not worth that sort of slavery.
I don't really mind Death so much. It's the danged recycling time, gearing up a new body and mind through the childhood stages that drives me nuts. HATE that oh-great-I'm-a-kid-again thing.
"HATE that oh-great-I'm-a-kid-again thing." ROTFLMAO! I hear this is an common issue with The Recycled. At least those who know they're recycled... ;D
Interesting, Ghost. My son's wife is denied because of her weight. Hmm...
JamaGenee: Yeah, I've heard I'm not alone on that one.
Susieq42: Hmmm indeed....
Ghost, you are, unfortunately, all too correct. I think if people could buy insurance cross-state a lot of post-event sudden "awareness" on the part of insurance execs would cease. As it is they have folks by the b*lls with one hand and squeezing 'em dry with the other. Please pardon the explicit imagery on that but I can't think of a more tasteful allegory right now.
LOL!
I laugh because--maybe it's a redhead thing--Pam uses the same term.
Nope, it's not a "redhead thing", just plain old truth! ;D
You think? :)
vocalcoach Level 7 Commenter 8 months ago
Ghost - Great hub! Loved learning this: " The war will escalate from there until they decide it's going to be more expensive to fight your Mom than to pay up."
Bookmarking this and rating UP. Thanks so much.