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TexLaw
TexLaw, Attorney
Category: Legal
Satisfied Customers: 4214
Experience:  Lead trial/International commercial attorney licensed 11 yrs
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I purchased a First Diagnosis Cancer Insurance Plan and was

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I purchased a First Diagnosis Cancer Insurance Plan and was recently diagnosed with cancer but the claim has been denied because they claim that it was a pre-existing condition. I had a nodule on the right side of my thyroid which I was monitoring since 2009 with my endocrinologist with ultrasounds and biopsies. The biopsies have always come back negative for cancer. The nodule continued to increase so surgery for removal was recommended, even though thyroid was functioning normally. This December 2012, the right side was removed and sent for examination.The pathology report showed signs of cancer cells evident. I had to return to surgery to have a complete thyroid removal after pathology reports. I filed with the insurance company because the plan pays only upon first diagnosis of cancer. They denied the claim because they say it was a pre-existing condition because signs or symptoms existed which would have caused an ordinarily prudent person to have sought diagnosis, advice or treatment. I believe they are wrong because I did everything I could in order to monitor nodule, with scans and biopsies. I was referred for a partial thyroid removal not for a cancer threat but for a nontoxic unimodular goiter.
Submitted: 1 year ago.
Category: Legal
Expert:  TexLaw replied 1 year ago.

Hi,

Thank you for your question and I'm sorry to hear about this situation.

You are correct in your assessment. The insurance company cannot deny your claim where you have in fact acted as a reasonably prudent person in seeking and obtaining treatment of the condition.

When insurance has been wrongly denied based on a misapplication of an exclusion under the policy, the insurance company has committed a breach of contract. Often, the insurance policy requires that you go through an appeal process. However, you can often file suit in lieu of completing the appeals process where you believe that the insurance company is simply acting in bad faith.

These sort of lawsuits can be very complicated and you will need to hire an attorney. A personal injury attorney is the best type of attorney to hire in this sort of claim. There are several that specialize in insurance claims and may be able to take your case on a contingency basis (without any up front cost to you).

Getting an attorney involved may also speed up the process of getting your claim paid even if it is through the internal appeal process.

Please let me know if you have any questions regarding my answer.

Best Regards,

ZDN

Customer: replied 1 year ago.

should i proceed with my appeal letter as a first try or try to find legal representation and forget the appeal letter

Expert:  TexLaw replied 1 year ago.

This really depends on whether you are going to want to take the risk of paying an attorney when you might be able to get the claim paid on your own. Remember, the attorney will likely take a case like this on contingency, which means that you might have to pay the attorney 35-45% of whatever you end up getting from the insurance company.

This is generally seen as pretty significant, so I would suggest going ahead with the appeal. I would also suggest going ahead and setting up some appointments with a few different attorneys to see if they would be interested in representing you if the appeal does not end favorably for you.

-ZDN

Customer: replied 1 year ago.

wow that much huh? this is only a $10,000 claim and I was hoping to use the money to help pay for medical costs of surgery


Ok thanks, XXXXX XXXXX submit my letter of appeal to them first. can I forward you my letter to see if there are any words i can add to make it more assertive or can you suggest any phrases I can add to make it more aggressive.

Expert:  TexLaw replied 1 year ago.

Please send the letter to: experts@justanswer.com as an attachment. IN the email, put the link to this question: http://www.justanswer.com/law/7kp4g-purchased-first-diagnosis-cancer-insurance-plan.html

And ask that the attachment be forwarded to zdnlaw.

Thanks,

ZDN

Customer: replied 1 year ago.

my e-mail would not allow me to send, viewed link as spam, so i sent it via my son's email

Expert:  TexLaw replied 1 year ago.

thanks.

I'll keep a look out for it. It may take some time to get to me, so thanks in advance for your patience.

Expert:  TexLaw replied 1 year ago.

Hi,

Sorry for the long wait. I finally received your email and reviewed your letter. I've made some changes and have copied and pasted the text below for your review.






February 18, 2013



Contract #2000086150



Claim# XXXXX



Claimant: Maria R. Lopez





Attention Health Claims:





I write this letter to formally
notify you that I dispute and protest the Insurer's denial of my claim for
benefits under the above-referenced policy.





Insurer has denied my
claim based on a review of my medical records obtained from Dr. Lourdes Concha,
my primary treating physician. Based on these records, the Insurer determined that
the cancer for which I am claiming coverage was the result of a pre-existing condition
for which I did not obtain reasonable medical treatment. However, the medical records clearly show
that the Insurer failed to properly analyze my claim and is wrongfully denying
my claim.





The medical records
indicated that I was being seen for a nodule on my thyroid as far back as 2009,
this is correct. Your letter also states
that I had ultrasounds that showed the nodule had increased in size over the
years, this is also correct. However,
your analysis fails to include the fact that I had numerous biopsies performed
between 2009-2012 in order to monitor the nodule for cancerous growth. These biopsies and scans, along with the
medication, Levothyroxine, were necessary precautions taken by a prudent person
with a nodule on her thyroid. The negative
biopsy results, scan results, and thyroid functioning normal, were taken into
consideration in order to avoid unnecessary surgery.





After biopsies conducted
were negative to cancer, but the nodule continued to increase minutely, Dr.
Concha recommended removal of right side of thyroid and proceeded to make an
appointment with surgeon Dr. Tan Nguyen during my July follow-up appointment
with my consent. The appointment was
made by her assistant for the next available appointment which was in
November. I proceeded with the
appointment, gave the referral listed by Dr. Concha as removal of right side of thyroid for
nontoxic unimodular goiter to Dr. Nguyen.
After Dr. Nguyen gave me dates he had available for surgery in December,
January, and February, we set the surgery day for December 10, 2012, to
coincide with Christmas vacations and help in the recovery time.











Again, I was referred for
a partial thyroid removal because of previous negative results of scans and cancer
biopsies. If I had a pre-existing cancer
diagnosis or had been given advice for cancer or treatment as your definition
states in your letter, I would have been recommended for a full thyroid
removal. On the contrary, I was NEVER
diagnosed with cancer as a result of the constant, reasonable and prudent
medical treatment I received for this condtion until the recent surgery. I took every precaution in monitoring nodule,
had thyroid scans in order to monitor growth, took medication in order to try
and stop growth, submitted myself to several painful biopsies which were all
NEGATIVE to cancer, and proceeded with referral to remove right side of thyroid
with certified surgeon Dr. Tan Nguyen when it was deemed necessary.





I am resubmitting the
latest report (7/23/12) from Dr. Concha's office and highlighting her
assessment which shows her referral to a surgeon for a nontoxic nodular goiter,
that the right thyroid nodule is negative for malignancy, and that the thyroid
was functioning normal and surgery to be done in December. Please contact her office if you need any
further clarification.





I demand that you
reevaluate this claim and review the policy that I purchased with your
company. I did everything a prudent
person should have done and I would hate to think that your company is acting
in bad faith in not fulfilling the contract.





Awaiting your reply,







Maria R. Gomez-Lopez



Expert:  TexLaw replied 1 year ago.

Hi Maria,

Please let me know if you have any further questions. Please also remember to rate my answer positively as I will not be compensated for my time and work on your question until you do so.

Thank you,

ZDN

TexLaw, Attorney
Category: Legal
Satisfied Customers: 4214
Experience: Lead trial/International commercial attorney licensed 11 yrs
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Lead trial/International commercial attorney licensed 11 yrs