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Personal Injury Pro
Personal Injury Pro, Attorney
Category: Personal Injury Law
Satisfied Customers: 6531
Experience:  Insurance Defense Attorney
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I was hospitalized from 12/12/11 through 12/23/11. and I had

Resolved Question:

I was hospitalized from 12/12/11 through 12/23/11. and I had a Hospital Accident Insurance Plan at the time. I have submitted several claims but they have said that my injury is not covered because it was due to a pre-existing condition. I went to the emergency room because I accidently injured my foot at home. I was not aware of any pre-existing condition. I found out about that after I had 5 hours of surgery. Can you give me any advice as to how I should proceed with my claim?
Submitted: 11 months ago.
Category: Personal Injury Law
Expert:  Personal Injury Pro replied 11 months ago.

Personal Injury Pro : Hello!
Personal Injury Pro : Have you filed an appeal yet?
Customer:

No not yet!

Personal Injury Pro : Okay, thank you. That will be your next step and I will give you information on how to best address this. However, in the meantime, CA also has a program where you can file a complaint against your health plan with the state. This will get the ball rolling on that side of things. You can do that right online here: https://wpso.dmhc.ca.gov/complaint/default.aspx?c=1
Customer:

okay

Personal Injury Pro : With regard to the appeal, first, figure out what led to the denial of coverage and learn your insurer’s procedure for appeals. When you call your health plan to get the information, take notes and get names. If the problem can’t be readily resolved, you should ask the insurer for some key documents to reconstruct what led to the rejection.
Personal Injury Pro : You will need the denial letter. You should also get a copy of your plan’s full benefits language, sometimes called the “Evidence of Coverage,” as well as the detailed guidelines that explain what the company considers medically necessary. Some companies, such as Cigna Corp. and Aetna Inc., post their medical policies online.
Personal Injury Pro : In your case, your appeal seems to hinge on proving that your treatment qualifies for coverage under your plan’s benefits and rules. In that case, you will want to zero in on the plan’s language, and figure out why the procedure fits into a category of care that the insurer has promised to pay for.
Personal Injury Pro : Your doctor should be able to write a detailed letter on your behalf stating that you were not aware of the injury before the operation, and thus, you had know knowledge you had a pre-existing condition.
Personal Injury Pro : Even if your insurer rejects your appeal, you still have other options. If your employer has a self-funded health plan, which might be administered by a private insurer but is backed by the employer, your next step is often to sue in federal court, a tough and expensive proposition.But if your coverage is with an insurance company, either through your employer or an individual policy, you can opt for your state’s appeals process. Often, these are handled through the state’s insurance regulator, but if not, this agency should at least be able to tell you where to go.
Personal Injury Pro : I think you are typing to me...I am happy to answer any additional questions you might have for me regarding this issue.
Customer:

I do know why they denied my last appeal. I do have the plans benefit language. First they denied my claim because they said that it was not an accident. I believe I proved to them that it was an accident because they know say that it does not meet there definition of Injury: means bodily harm or damage due to an accident that is not contributed to by disease,illness,infection,bodily infirmity or any other abnormal physical condition. How can they have such a definition for Injury? It would probably get them out of paying 90 percent of the claims they get?

Customer:

I am not a very fast typer

Personal Injury Pro : No worries! :) reading your last response.
Personal Injury Pro : As I understand it, you injured your foot and had to have surgery. But the insurance company is denying you coverage of the surgery because they are saying the reason you had surgery was due to a pre existing condition. Is that correct?
Customer:

yes exactly

Personal Injury Pro : Thank you. A letter from your doctor saying that the injury was recent was was not prexisting should suffice as enough evidence for you to be successful in your appeal but also, filing that complaint with the CA Insurance Board should help as well. Once your insurance company realizes the state is involved, things should go quite smoothly for you.
Personal Injury Pro : That should say "and was not prexisting..."
Customer:

This is what they said in there claim deniel letter, The admitting diagnosis listed on the bill for your emergency room treatment and hospital confinement was atherosclerosis of the extremities with gangrene and that the principal diagnosis was the same. They say that the admitting diagnosis is defined as the condition identified by the physician at the time the patient's admission required hospitalization. and that the principal is defined as the condition that is chiefly responsible for the admission.

Personal Injury Pro : How did you hurt your foot?
Customer:

I jammed my foot (left) on my bedroom door. I did this just as I was leaving on vacation (flying back to Minnesota)

Personal Injury Pro : Okay. So you went to the ER because you hurt your foot but the doctor's did some test and determined you needed to have surgery because you had a prexisting condition. You're going to have to get the state involved in this one because the doctor is going to have to change the admitting diagnosis. You can try to get them to do that on your own, but having a state advocate is a safer bet.
Personal Injury Pro : You may want to start by seeking help from one of the array of nonprofit and for-profit entities that offer advice. Many states have health insurance consumer advocates. The advocacy group Families USA offers a list of state resources.Another key resource is the nonprofit Patient Advocate Foundation, which handles health-insurance appeals for free. Other organizations and companies can be found at the following Web sites:Claims.orgHospitalbillreview.comHealthproponent.comBilladvocates.comHealthchampion.netPatientcare4u.com.
Customer:

Okay! What will I need to provied to the state advocate?

Personal Injury Pro : Sorry, those ran together. Here they are again: Claims.org
Personal Injury Pro : Hospitalbillreview.com
Personal Injury Pro : Healthproponent.com
Personal Injury Pro : Billadvocates.com
Personal Injury Pro : Healthchampion.net
Personal Injury Pro : Patientcare4u.com
Personal Injury Pro : Just follow the claim form I provided to you and it will let you know.
Personal Injury Pro : I am happy to answer any further questions you might have for me at this time! :)
Customer:

What claim form?

Personal Injury Pro : The one I gave you to file a complaint/claim online here: https://wpso.dmhc.ca.gov/complaint/default.aspx?c=1
Customer:

Okay, Thanks

Personal Injury Pro : My pleasure! If there Is there anything further I can help you with at this time, please let me know. I strive for excellent service and I hope I have provided that to you this evening.
Customer:

That you have. Thanks again

Personal Injury Pro, Attorney
Satisfied Customers: 6531
Experience: Insurance Defense Attorney
Personal Injury Pro and 4 other Personal Injury Law Specialists are ready to help you
Expert:  Personal Injury Pro replied 11 months ago.
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