Question
What is the name of your state? Florida
My adult daughter had surgery for a non-malignant tumor growing in her ear canal area. The tumor was quite large and the ENT was worried not only that her hearing was gone (2 bones had disintigrated), but that it was going to grow into her brain tissue. She had had hearing problems for some time, but did nothing, thinking it was ear wax or loud music. She woke up one morning with no hearing. The ENT cleaned the wax out of both ears and then discovered the problem, and ordered a catscan.
She also has to have two more surgeries. One to repair the missing bones to regain some of her hearing hopefully and a third to remove the start of a tumor in the second ear.
The secend surgery was suppose to be scheduled for next month.
My daughter found out the insurance company has refused to pay for her surgery, though she used a doctor under her policy (United Healthcare). They also refused to pay the hospital. I don't have to tell you it adds up to thousands. The reason stated is that this policy is new (6 months) and they are saying it's a prior health problem that she must have known about. Of course, this is ridiculous. How would anyone know they have a tumor growing in their ear without medical attention. It took a catscan to locate the problem. She has had no insurance since turning 18 and for that reason hasn't seen any doctors in that time period.
That also means she won't be covered for the second and third surgeries either, nor subsquent care (the doctor has inidcated that she will need periodic catscans to be sure the tumors are not growing back - for the rest of her life). She is only 24 years old and that is a long time.
Does anyone have any idea how to deal with the insurance company??? I am totally at a lose as to where to start and she is hysteric as to how she's going to pay for all the surgery. Thanks.
Jane
editing in - she has a group policy with United Healthcare through her employer.
Answer
Midnight,
You should have an expert review the precise policy language dealing with pre-existing conditions and consider appealing this decision.
The common definition of a pre-existing condition is..." a condition that manifests symptoms that would cause an ordinarily prudent person to seek medical treatment...". However, most group policies are required by state regulations to have more narrow language and this should also be researched.
Finally, since this is thru her work, the plan falls under the federal ERISA laws and therefore it is very important that you follow the administrative appeals process. How you handle the appeal will be very important. Also, there may be a time limit on appealing.
Good luck and let us know if we can help.
Answer
CIAA - thank you for your advice. I am calling my daugther about this first thing in the morning. Again...thanks.
Jane
Answer
Have your doughters HR get involved. They should be able to help