Question
What is the name of your state? Florida
My wife recently was hospitalized for a bad reaction/overdose to prescription medication she had taken (valium), she had been taken other medications for depression and recently stopped taking these medicines (on her own) and had been taking the valium prescription for several days when she overdosed. She was hospitalized and then sent to a mental health facility for several days of observation and is now doing fine.
The insurance HMO says this is not covered because it was a self inflicted injury. I believe the heart of the matter is that they feel this was an attempted suicide and therefore not covered. I am wondering if they have to prove this or is the burden of proof on me to prove that it wasn't attempted suicide. I feel that this whole incident was caused by a reaction she had when she stopped taking the one medicine abruptly and then was prescribed another medicine by a different doctor. In hindsight this was stupid on her part but I think insurance should still cover my medical expenses.
Can someone comment on an insurance companies rights to deny coverage for attempted suicide (even if it may have been caused, at least partially, by a reaction to the prescription medication she was taking at the time). What are my legal rights if any?
Thanks,
Answer
What are my legal rights if any?
File an appeal with your carrier & supply documents that support you.
From my experience claims are processed based on:
1) Diagnosis
2) Procedure
3) Documentation
Insurance carriers do not reject claims to save money or cause members problems (Some Insurance carriers are non profit). Insurance carriers reject claims because benefits were not available at the time of service.
I do not want to sound pro insurance but, I am quite sure you have no idea what was sent to your carrier (claim,documentaion & labwork). The doctors chart notes could specifically show that signs of self injury were deliberate or they could say the exact opposite (I have no idea). If you do know what was included please share what you can with us.
Please take the time to calmly talk with your carrier & doctor about this issue. You may be required to provide copies of chart notes etc at your own cost so keep this in mind when you ask for them (Some people decide to yell and scream about paying).
Remember, something on the claim or in documentation flagged your wife's claim as non covered. You need to find that information and squash it in your appeal.