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
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
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
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