Advice? Health insurance related.

[Liz]

As some of you may know, my daughter had a heart transplant 20 years ago. Today we found out the insurance company won’t pay any more of her transplant related expenses. She has a $500,000 lifetime limit generally but someone now has noticed in the benefits booklet it says:

ORGAN TRANSPLANTS: $100,000 after deductible lifetime limit

They say they have paid approx. $250,000 OVER the $100,000 limit. To us it seems that category of “organ transplants” is open to interpretation. We (of course) think that means the actual TRANSPLANT expense (she didn’t have this same insurance at the time of transplant). They are now saying that includes all related follow up visits with the cardiologist, medication, etc. We think just by the fact they have paid $350,000 towards follow up care that right there indicates it’s not what it means.

They also say they “don’t know yet” whether we have to pay back the “overage”. I suppose I should be worried about that but I’m not. We don’t have the money to pay it back and if they force the issue we’d be bankrupt.

Just posting here to see if anyone has any advice. The head of the insurance company is out of town for a week so our next step is to talk to him when he returns. They also said we can appeal to a board but I don’t know how that would turn out.

 

[ameraumi]

Is the policy thru an employer? If so, get them involved as well.

I agree though, if it did not say "and related expenses" then I would believe it was for transplants only.

 

[mickeyboat]

Yes, get your employer involved, and your employer's insurance agent. Also ask the doctor's office / hospital to get involved. They probably have a patient financial services department that can help.

Ask the insurance company for a copy of your certificate of coverage, if you don't already have one. It should specifically detail your coverage and note all the relevant definitions.

Good luck. It sounds scary to me.

 

[Liz]

This is health insurance through a union. I don't know if that makes a difference.

Also we are sort of between doctors at the moment. She was just "released" from pediatric care and we are supposed to have our first visit with the adult program docs in August or September. Just a bad time for this to be happening.

 

[Disney Doll]

I might give the insurance commissioner in your state a call and tell them your story and see what input they might have.

 

[disbridemimi]

Sent you a PM, I second the calling of the insurance commisioner.Your state should have an ombudsman that can intervene on your behalf, like a middle man. I also think you may need a lawyer. I hate health insurance companies. Where is Michael Moore when you need him?