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INC
INC, Solicitor-Advocate
Category: European Law
Satisfied Customers: 95
Experience:  LL.B, LPC, LL.M, Pg.Dip, Solicitor-Advocate. UK Practising Certificate issued by SRA., DIFC Courts Registered (Dubai)
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MY HEALTH INSURANCE COMPANY HAS REFUSED MY CLAIM FOR A REPLACEMENT

Customer Question

MY HEALTH INSURANCE COMPANY HAS REFUSED MY CLAIM FOR A REPLACEMENT OF MY LEG PROSTHESIS WHICH HAS BEEN TWICE APPROVED AND REIMBURSED IN THE PAST 15 YEARS
Submitted: 3 years ago.
Category: European Law
Expert:  Fran-mod replied 3 years ago.
Hi, I'm a moderator for this topic. I've been working hard to find a professional to assist you right away, but sometimes finding the right professional can take a little longer than expected.

I wonder whether you're ok with continuing to wait for an answer. If you are, please let me know and I will continue my search. If not, feel free to let me know and I will cancel this question for you. Thank you!
Customer: replied 3 years ago.

Heath insurance plan is American.


 


I am an 86 year old US citizen living in Italy, retired after 40 years of service as
a Department of the Army Civilian at a US Army base (Camp Darby) located in Pisa. As
a government employee and retiree I have been continuously enrolled for more than 30
years in the Mail Handlers Benefit Plan (MHBP) ID number XXXXXXXXXXX an approved
health insurance plan sponsored and partially paid for, by the US Office of Personnel
Management (OPM). The monthly payment to MHBp currently deducted from my retirement pay
is some $450 a month.

I have been an invalid since 1996 when my right leg was amputated above the knee and
have had to wear an artificial limb with an electronic knee to be able to walk. These
expensive ($32,800) electronic knees are guaranteed for 3 years with an additional 2 year
extension. After the maximum guarantee period the manufacturer recommends replacement of
the knee if it is not satisfactorily functional. The MHBP has reimbursed the acquisition
of two of these legs. In December 2012 I submitted a claim to MHBP for replacement of
my 13 year old leg. This claim included the same supporting documents as the two
previously approved claims, a bill with English translation for the cost of the knee
and the cost of construction and fitting of the stump socket, prepared and signed by
the provider,as well as required information specified on the claims form.

The first reply I received was a letter with date 01/02/2013,entitled "EXPLANATION
OF BENEFITS" which specified, that the billed Amount, $37,254.85 (actually the amount I
claimed 29,952 EURO) was ineligible for reimbursement. A remarks paragraph stated
"RESUBMIT WITH CURRENCY USED, ITEMIZED BILL, DIAGNOSIS OR REASON FOR SERVICES AND
TRANSLATION". Although my original claim contained all required information, including
translation I resubmitted the claim. I also sent a letter specifying that MHBP had already
reimbursed for two knees in the past and that my condition was rapidly becoming urgent
and required expeditious processing.

I did not receive a reply until 23 May 2013. The letter had a date of 04/25/2013 and
again declared the billed amount ineligible with the remarks paragraph: (SERVICE
LACKS INFORMATION FOR PROCESSING. SEND ADDITIONAL DETAIL/ITEMIZATION WITH DOS & REV
CODES). I immediately replied by FAX with step by step instructions on constructing
limb prosthesis sockets which I found via internet. I also told them my condition
deteriorated to the point that I can no longer leave the house without the use a wheel
chair and an accompanying person. As for the DOS and REV codes I called MHBP with the
telephone number the letter indicated for clarification and the clerk told me that
they were codes used for determining charges for hospital services and were not
applicable for oversea services.











Expert:  Fran-mod replied 3 years ago.
Hello Edward,

Thank you for your patience. We will continue the search for a professional for you.
Expert:  T.DePas replied 3 years ago.
Dear Edward,

Thank you for contacting JustAnswer.

Could you please specify better your question?

I look forward to hearing from you.

Best,

Tiziana