LymeNet Flash: Insurance Denies My Claim

This is topic Insurance Denies My Claim in forum Medical Questions at LymeNet Flash.

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Posted by morningnewsman (Member # 5987) on :

My LLMD is out of network....I went to him because in-network docs told me for a year that I had either nothing wrong or all kinds of things...some said flat-out I did not have Lyme. Now my LLMD has proved I DO have Lyme.
Now my insurance company has denied my claims for covering my treatment and medication....I had to appear before their 2nd level appeal committee, and they still denied me because my LLMD is out of network.
I had NO CHOICE but to go to this LLMD, who has be out of bed and back to work. Any thoughts on how I can fight the insurance company who claims to "put the customers mind at ease and let them know their needs will be met". Thanks.

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Thanks,
Rick

Posted by flygirl (Member # 6669) on :

wait, an insurance company can deny drugs if they are from an out of network doctor? oh Sh8t my doc is out of network as of Jan 1!

$%^&*( insurance companies

Posted by zipzip (Member # 6226) on :

i'm not to familiar with insurance problems and lyme fortunately.

you can ask for an indepedent committee to review your medical history and make recommendations for the insurance company.

this may or may not work in your favor btw.

be sure to talk your insurance broker and find out who all the major player are in your insurance company and write them personal letters of complaint.

also ask the insurance broker what strategies may help you with resoltution of these charges.

if you keep pressing the insurance compnay they will eventually cave, they always do. they are counting on you to give up, you must have infinite patience and reserve.

also ask your LLMD if you can get a letter of medical neccessity for your treatment and meds. this will help tremendously.

Posted by James H (Member # 6380) on :

Go to your in-network physician that is NOT giving you proper care, and demand all of your medical records.

Do not give a reason.

Do not accept 'no', as you are entitled to them anytime you ask.

They will assume you are filing a lawsuit and sometimes suddenly become much more cooperative.

Posted by duramater (Member # 6480) on :

Every state has a division or department of insurance. One of the things they do is investigate claims that the insurance company should pay but aren't. They have one of their lawyers check out all of your information, documentation, appeals, etc. versus what the insurance company provides and make a determination. It is free but takes about 6 months for the whole thing.

Back when I lived in NJ, my insurance company dorked me on a HUGE bill (related to Lyme) and after going back and forth with them for a while, an advocate at a local hospital (who had nothing to do with any of this, she was just super kind), helped me file my claim with the state.

After six months, I received a determination in my favor stating that if the insurance company didn't pay the bill within 7 days, to let the department know because big bad horrible things would happen to the insurance company.

The whole process wasn't too hard, you just had to provide documentation of your side of the story and then patiently wait.

Anyway, that is something to check out.

Best of luck,
DM

Posted by Neil M Martin (Member # 2357) on :

Consider yourself lucky. You have a denial!

Back in 1999 I claimed jaw surgery and Lyme IV antibiotics (which I had to get out of plan due to HMO misdiagnoses). When they said "NO" I stupidly followed them down the garden path to thier arbitrator - who upheld the denial on flimsy/insane pretexts. I was too weak to press the matter from there. My health came first.

In 2000-2001 I file another claim. When the denial arrivewd I took it to the state Dept of Insurance for arbitration - which upheld the denial but allowed me to see an ALJ. At ALJ hearing I got a level playing field. DOI then got on the HMO and it PAID.

In 2002 I filed $10,000 in out of network IV antibiotics. My HMO directed me to hoops and meaningless, adversarial delays and I never did get my claim upheld or denied.

At one point I was in limbo for 12 maddening months.

I called my senator, completed his privacy form and jumped through his hoops and GLORY BE he found out how my HMO abused me and turned on them!

And I GOT PAID.

40 months' effort BUT IT WAS WORTH IT as I recovered most of what they failed to pay 1998-2001.
http://www.harp.org/#fad
Insurance, Disability Claims, Health Costs, and HMO Issues and Lyme Disease

See link "fighting a denial" (Includes "HMO HARDBALL")
http://www.hmohardball.com/

"10 'Dirty Tricks'"
http://www.rescuehealthcareday.com/10DirtyTricks.htm

Links to Lyme disease claims-processing
http://www.geocities.com/HotSprings/Oasis/6455/insurance-links.html

Posted by snowboarder (Member # 6346) on :

The above inforamtion is great but I thought of one more thing...there is patient advocates in different states that can help you with claims that are denied.

I have no idea how she got a hold of one but I'll send her an email right now and get back to you.

My neighbor used one when her daughter's claims were denied and she won.

Do you have a lawyer you could talk to and see what recommendations and legal adive they can give you?

I'd personally go after them from a legal stand point if you can afford to financially to make an example of them.

One thing you want to keep in mind with the Insurance Commissioner at least in the state I reside in is you need to keep hounding and calling them because in this state, the Insurance Commissioner is the biggest joke.

Best of luck and keep us posted!

Posted by minoucat (Member # 5175) on :

Just to second what everyone's said -- I've had to fight both the insurance companies and disability several times. If you don't give up, you usually win.

When we made it clear we were going to court, and that each denial would be treated separately (at one point, that meant the ins. co would have to make 6 separate court appearances), the insurance company paid our claims. We had thorough documentation, and they knew it. It took from 12 to 36 months for us to win our appeals.

Just be sure you have a thorough medical history and all your medical records. Get postal receipts on everything you submit. Document your physical limitations and not just your diagnosis. Cite the medical literature -- there is a wealth of information on this site, and at http://www.lymeinfo.net/lymefiles.html We got advice from an attorney, as well.

When you're sick and exhausted, this seems like a tremendous amount of work. But do one step at a time, and you'll get there.

Let us know how it goes.

Posted by flygirl (Member # 6669) on :

minoucast - smart insurance company. I think they quickly figured out the legal bills would far outstrip the cost to just pay you (their moral and legal obligation) and shut the hell up.

I HATE insurance companies.

Posted by sofy (Member # 5721) on :

I cant relate exactly to your problem but when my insurance denied paying for the genetic testing my lyme doc did on my I called and asked why.

They said they only did that testing for liver transplant patients.

I asked my doc for papers documenting why I needed the testing.

Bundles them into a large manilla envelope and spent a couple dollars on postage. There were so many papers that they just capitulated and paid with no ??? asked.

When going to a committe I suspect its a lot different.

Im hoping this might give you some bit of an idea or clue as to how to proceed.

You beat the lyme thing and got back to work you are tough enough to stand up and beat these guys

Posted by morningnewsman (Member # 5987) on :

Thanks for all the information! They told me my contract clearly states that they don't cover out of network doctors, unless in the case of emergency. After deteriorating for a year, losing my job, my apartment, ending up bed-ridden, and having doctors still saying nothing was wrong....I considered that an emergency. We are speaking with lawyers about the next step in the process.
I cannot believe they leave folks in such bad spots and don't want to support you. I'm gonna make a big example of them, be sure. I've been lucky to have a solid family and support network...but what about those who don't? These insurance companies must do so much more.
Thanks!

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Thanks,
Rick

Posted by bg (Member # 46416) on :

Rick, go also to: EDITED...correct site is:
http://groups.yahoo.com/group/Disinissues/

which stands for "DISABILITY INSURANCE ISSUES" ... a wealth of good info there.

Go to their files/links & print off the screens shown...they will help you.

Print off the female drs. SSDI app..possibly 20 pages giving you specific ideas on how to word things showing you can no longer work using their 8 things: standing, walking, sitting, bending, crawling, hand jobs, etc.

Look at all the pertinent stuff BEFORE you decide to file your SSDI claim so it can be approved on the 1st step of your 1st claim only!

Read my today's topic on APPEALS COUNCIL denies me. I've been in this God awful mess for 4 yrs. 4 months without success.
Best wishes, Betty G., Iowa

[This message has been edited by bettyg (edited 29 December 2004).]

Posted by Neil M Martin (Member # 2357) on :

The last link did not "spool".

See if HMO contract allows out of plan treatment for urgent conditions, too.

Some limit emergencies to "seconds count, rush-to-the-hospital" events.

I won my first HMO case at a hearing by reading their definition of "emergency" word for word. My jawbone infections was just that (I also had out of plan Dr. say it was emergency).

My HMO retorted that because they didn't treat my jaw infectinos when acute, the infections were chronic, not "emergent".

They also chided me for not getting my jaw surgerized sooner. It made complete sense to them but the Judge was not impressed.

Neil

Posted by guiney (Member # 4550) on :

Hey, Rick, I really haven't read all of your replies....so if someone already gave you this link, ....well....then you have it again

http://www.geocities.com/HotSprings/Oasis/6455/insurance-links.html

good luck, guiney

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Posted by flygirl (Member # 6669) on :

I think you should make an example of them. bleed them dry and show no mercy. not joking. I HATE insurance companies.

Posted by bg (Member # 46416) on :

Neil, thanks for catching my mistake on disinissues correct web site...I corrected that.

Guiney, is the wonderful insurance site info on lyme on TREEPATROL & TINCUP'S newbie links? If not, please post it to their posts also! Thanks so much getting these valuable links in all one place.
Betty G., Iowa

Posted by morningnewsman (Member # 5987) on :

Thank you all so much for this information....the links have so much stuff that I've been printing out and reading!
Lyme has cost me tens of thousands in medication, visits, missed work, doctors bills when they mis-diagnosed me for a year!
I hope many others can learn from all this info you have posted here too, and I'll keep you informed on the progress. I still cannot believe that I met with a seven-person conference, layed out my situation, and they STILL denied me, saying they don't cover out of network doctors, unless it's an emergency. Insurance is supposed to help in situations exactly like this!
Thanks again,
Rick

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Thanks,
Rick

Posted by Pitnum (Member # 4906) on :

My claim was initially denied by the insurance company also........my LLMD is also out of network. Since the insurance company did not have an LLMD in network, they were forced to pay the entire bill. They must also pay for ongoing treatment.......yet they still refuse to allow the LLMD in network! Makes no sense!