Been Denied Care? … take Hope, there IS a Solution!

(11:00AM EST – promoted by Nightprowlkitty)

cross-posted on the kos — Health Insurance

Question: What is a pre-existing condition exclusion period?

Answer: Insurance companies try to discourage people from waiting until they get sick in order to purchase health insurance. One way in which they do this is to impose pre-existing condition exclusion periods. This means that if you have a medical problem which exists at the time you enroll in or purchase your health insurance, the insurance company will deny all claims pertaining to this medical problem for a certain period of time.

(emphasis added)


So there IS Hope —

Just Stay at that Job Forever

Or NEVER get Sick —

And NO Problem!!!

They got you covered!  (as long as you can live with “Job Lock”)

Perhaps you too have been the victim of such Catch-22 Clauses of our friendly national Health Insurance Industry? Perhaps you too, have witnessed, friends and family, be denied the Care they needed — or worse yet, refuse to seek the Care in the first place for fear of placing the burden of “uncovered bills” on their family, after they’re gone?

Perhaps, you have inherited a stack of such unpaid bills, because some Private Insurance “Claim Denial” Specialist, stood between your love one and their Doctors — and that Private Company, just refused to pay?  

God forbid you should get one of those “Big Three” diseases, which triggers your Insurer to Drop your Policy for no reason at all whatever petty trumped up trivial “reason” they can find!

Well actually Industry Insiders, don’t call it “Dropping”, they prefer to call it “Purging the less Profitable Policies“!  At least according to former “Insurance Exec”, Wendell Potter, who is spilling the beans to Congress about such Obstructionist Tactics, routinely employed by your friendly national Health Insurance Industry.

With “Care Management” like that — who Needs Government intervention to get in the way?  

Insurers already got it covered!Just Trust Them!

Or perhaps, you’re just an average “worker bee”, bewildered by the “obstacle course” Maze of Insurance Policy “fine print”? Perhaps you’re worried about the overall trends of ever-increasing “out of pocket” costs, in exchange for ever-decreasing Quality of Care?

(Given the annual increases in Insurance Co-Pays and Paycheck Deductions over the last several years, perhaps like me, you have been kissing that annual Raise goodbye, as soon as you get it, assuming you’re lucky enough to still be “stuck in” a job, with “benefits”?)

Take Heart, you’re NOT Alone!

U.S. Consumers Demand Transparency and Accountability from Health Care Organizations, PNC Survey Finds

PRWeb — June 12, 2007

Consumers More Aware of Medical Billing and Administration

As health care consumers, Americans are paying closer attention to their health care bills, especially Americans with a high deductible health plan. Yet one-third of respondents have trouble understanding the explanation of their health care insurance benefits, and nearly one-quarter report problems getting answers from their insurance company about the status of a medical claim.

Additional survey findings include:

   — One-third (33 percent) of consumers surveyed said that in the past year, they have had to contact their health plan at least once to resolve a claim, while one-quarter (26 percent) said they had to call two to three times.

   — Fifteen percent of consumers said they pay their medical bills even if the bill has an error.

   — Six in 10 consumers (60 percent) did not know that there is a limit on the time they can dispute a claim denial.

“Despite their interest in more transparency, many consumers struggle to understand the details of their medical bills and the payment process,” said Fryland.

(emphasis added)…

But don’t give up hope, Just break out the Legal Guide, and struggle through all that “fine print”, just contact all the right people, and push the right buttons, you TOO can find a Solution to your Health Care Payment Denial problems!

It’s easy!Even a lone citizen can dispute a Denial Claim — AND Win! … In America — anything’s Possible – right? Guide to Health Insurance

Don’t Lose Heart – Claims Dispute Success Story

By Kelly Montgomery, Tuesday July 22, 2008

If your insurance company denies coverage for a benefit you think you should have, you may be feeling overwhelmed by the difficulty of fighting for coverage. But don’t lose heart – it is possible to fight the claims denial, and win!

A recent article in the Syracuse Post-Standard shows how one woman complained [and won …]

(emphasis added)


If your Health Care bills have been Denied — YOU TOO can complain, and WIN — with even better Odds than winning the Lottery!

All you need to do, if find this handy Form Letter, Fill it out, and Hope! … Hope someone cares, hope that SOMEONE will hear your plight, and hope they choose to Fight for you — the lowly PATIENT WITH INSURANCE!

We all know, such citizen action, CAN effect Change, but will it, in your case?

You never know, til you try:

Sample letter of appeal for a health insurance claim denied as “not medically necessary”


[Your name]

[Your address]

[Your city, state, ZIP]

[Your phone number]


Attn: Director of Claims

[Name of insurance company]

[Insurance company address]

[City, state, ZIP]


    Patient: [patient name]

    Policy: [insurance policy number]

    Insured: [name of patient or insured person]

    Treatment dates: [admission date] – [discharge date]

    Amount: [total charges]

Dear [Mr./Ms./Director of Claims name, if available],

You recently denied a claim on the grounds that the care provided by [name of provider] on [date of services] was not medically necessary.

Denial of this claim was not justified and I am appealing the denial. The explanation of benefits did not give adequate information to establish the validity of this decision. Therefore, please provide the following information to support the denial of this treatment.

Please furnish the name and credentials of the insurance representative who reviewed the treatment records. Also, please provide an outline of the specific records reviewed and a description of any records that would be necessary in order to approve the treatment.

Also, please furnish copies of any expert medical opinions that have been secured by your company regarding treatment of this nature so that the treating physician may respond to its applicability to [my/this patient’s condition].

Please review this claim again. The information is correct [or has been corrected] to reflect the appropriate diagnosis and treatment. If you need further information or a medical report, please inform me within 10 days.

I can be reached at the following telephone number(s):

Daytime: [your phone number]

Evening: [your phone number]

Thank you for your prompt attention to this matter.


[your signature here]

(emphasis added)…

If you say “Please” at least 3 times, they’re suppose to Hear you right?

If that Solution to your Health Care affordability dilemmas, leaves you dumbfounded — and perplexed, and upset.

Well there is always another kind of Letter, that you can resort to.

Just don’t “hold your breath” waiting for an answer:


[Letter] To the Editor [New York Times]:

Under the guise of cutting “avoidable deaths,” the Federal Health Care Financing Administration is setting up a quota system that can have the sole result of rationing health care for Medicare patients.

Even Senator [$$$$$], who sponsored the bill setting up the program, admitted that he is “. . . seeing something here that I did not expect to see”

But it took an unnamed Health and Human Services official to reveal, “We will have independent medical review groups . . . to be sure they do not too aggressively deny care that is needed.”

Deny, but not too aggressively, indeed! This could only result in refusing admissions of the seriously ill as well as those with

mild heart attacks or

partially broken hips.


JACK C. SCHOENHOLTZ, M.D. Chairman, New York State Association of Private Psychiatric Hospitals Rye, N.Y.,

Aug. 7, 1984

(emphasis added)…

Old story, BUT the same message

Funny even Doctors get ignored, by our Congress,

Unless that have “paid representation” speaking for them that is!

Charles Grassley

Max(-imilian) Baucus

Glad some interests, get the Care THEY Deserve!

Woo hoo!  Goooo Private Insurance Industry!

Afterall Care Denial is GOOD for the Bottom lines, for those who matter!

Photo Art by Stephen Hansen

It seems, SOME THINGS, will Never Change — no matter how “Hard” we hope …


    • jamess on June 28, 2009 at 21:39

    tips for taking the Status Quo

    down a peg, or three!

    • jamess on June 29, 2009 at 03:07

    that will put you on the Insurer’s Radar, for Policy Cancellation …

    Well here are the top four Ailments, that makes you a “bad investment” for “Big Insurance”:

    breast cancer, lymphoma, pregnancy and high blood pressure

    … and unfortunately many, many more.

    Well, Well … Going to Healthcare Hell …

    by Donna Smith – June 18th, 2009 – Commondreams

    While here in the United States, we let insurance companies not only get in between our doctors and patients but actually block them ever seeing one another. This week we heard testimony in a Congressional committee that the insurance companies our President and Congress want so desperately to protect have no intention of stopping the practice of policy rescissions.

    Rescissions happen when you get sick, file an insurance claim and then the insurance company searches your records to find reasons they would have denied you coverage before your illness and then retroactively drops your coverage. And their favorite targets? The committee found, according to the Los Angeles Times, “WellPoint’s Blue Cross targeted individuals with more than 1,400 conditions, including breast cancer, lymphoma, pregnancy and high blood pressure.” Ugly stuff. And talk about getting between you and your doctor

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