Results 1 to 4 of 4
  1. #1
    Join Date
    Aug 2008
    Location
    Florida
    Posts
    2

    Default Denied Claim by Refusing to Determine if Pre-Existing

    My question involves insurance law for the state of: Florida

    Hello,
    My insurance provider seems to have found an interesting way to deny my claim and I am hoping one of the experts here could shed some light on how this can be possible. In short, I had a 6 month gap in insurance prior to my new policy with the denying insurer. Pre-existing clause is in effect due to the gap in coverage. 3 months into my policy I start having a persistent neck pain. I go to the doctor and get an MRI of the neck. Dr. says I need surgery and we schedule it. 3 days before the surgery the doctors office calls and says that my insurance company will not authorize the procedure because it could be a pre-existing condition. They refuse to determine if it is in fact pre-existing until AFTER the surgery. The surgery costs close to $30,000 so there is no way I can afford to get the surgery done with the hope that it might get approved afterwards. The insurance company states that they are not denying the claim. I sent them all of my medical records and they refuse to determine if the condition is pre-existing.

    What do you think?

    Thanks. Toflo

  2. #2
    Join Date
    Mar 2008
    Posts
    176

    Default Re: Denied Claim by Refusing to Determine if Pre-Existing

    prior to the 6 months did you have prior health coverage? if so, did you submit your credibility of coverage letter from your prior insurance? have you been seen by any doctor or receive any type of prescriptions during that 6 months prior to your new insurance becoming effective? was there a waiting period with your new plan? what was your hire date and when did your insurance become effective? the insurance company needs to see everything before your coverage became effective. how long ago did you send paperwork to them? What do you mean they refuse to determine? Have you submitted the names of all doctors you have seen and complete their paperwork? plus letters to your doctors have to be sent back to the insurance company (did they do that)

  3. #3
    Join Date
    Aug 2008
    Location
    Florida
    Posts
    2

    Default Re: Denied Claim by Refusing to Determine if Pre-Existing

    I had coverage up until 7 months prior to the start of my new plan. I had not seen a doctor for anything for 2 years prior and even then it was just for some antibiotics for the Flu. I am self employed so there is no hire date or anything. I sent them all of the medical records from the doctor I went to see when the neck pain started. There are no other records because I haven't seen a doctor in 2 years. They said that they "looked" at the medical records I sent them but that they refuse to make a determination wether or not it is a pre-existing condition. It seems quite simple to me but maybe I am missing something. They are refusing to determine if there is a pre-existing condition so they don't have to pay the claim. It's brilliant really. I just don't know if it is in good faith.

  4. #4
    Join Date
    Mar 2008
    Posts
    176

    Default Re: Denied Claim by Refusing to Determine if Pre-Existing

    did you submit your credibility of coverage letter from your prior insurance? you need to get that on record right away. Second you need to put in writing that you have not seen any doctors in 2 years and the one you have seen for the flu, give them the complete name and address of his office. ask your doctor if he sent in his paperwork.

    What do you mean they refuse to determine? have they sent you a denial letter? also was it 6 months or 7 months that you did not have insurance?

    1. Sponsored Links
       

Similar Threads

  1. Legal Research: How to Determine if a Claim is Moot
    By tony17112acst in forum Legal Practice
    Replies: 10
    Last Post: 05-02-2011, 11:08 AM
  2. Tourist Visas: If a B2 is Denied How Will This Affect My Existing ESTA and Upcoming Trip
    By holiday in forum Visas for Business, Tourism and Family
    Replies: 4
    Last Post: 10-25-2010, 02:32 AM
  3. Health Insurance: Insurance Denied Based on Pre-Existing Condition
    By GK1979 in forum Insurance Law
    Replies: 1
    Last Post: 06-16-2009, 06:03 AM
  4. Health Insurance: Liver Disease Claims Being Denied As Pre-Existing
    By cthen in forum Insurance Law
    Replies: 6
    Last Post: 02-01-2009, 07:05 AM
  5. Health Insurance: Gallstone Treatment Denied as a Pre-Existing Condition
    By karinagomez in forum Insurance Law
    Replies: 27
    Last Post: 11-07-2008, 02:04 PM
 
 
Sponsored Links

Legal Help, Information and Resources