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Question
Health insurance claim denied despite proof of coverage?
To make a long story short, I have several claims from summer of 2007 that are being repeatedly denied by my ex-insurance company due to their claims that I was not covered for those dates. My previous employer (a large well-known international retail business) has both been on conference call with me and sent a letter in writing to the insurance company clarifying my coverage dates. The claims are still being denied. When my HR dept is open again I will make one more call to ask them to verify, but if this denial occurs again, what are my options? Should I compile a bunch of paperwork and send it to a higher up at the ins. co? Should I be hiring a lawyer? The insurance agent clearly expressed doubt on the phone WITH my benefits department regarding their records. They obviously do not want to take responsibility for these bills. I've wasted so much time going back and forth with them...help! Here's the ironic part. A conference call was already made prior to my second denial. The rep blatantly doubted my employer's records, but said records would be updated. My employer also followed up with a written statement of coverage. Denied again. Then, I was informed they would call my employer and I also sent them paycheck stubs showing I was paying for insurance. I was told following their phone call to my employer, they would personally respond with status, which never happened.
2 months ago - 5 answers
Best Answer
Chosen by Asker
If the problem is with your effective dates, your previous employer is the only one who has the correct documentation and power to get this resolved. Usually, the employer has a specific contact person at the insurance company to get these types of issues resolved. They definately need to go higher in the "food chain" here. Make sure you get copies of whatever documentation your previous employer has sent or will be sent. Then once you receive that, send a followup letter to the insurance company and CC your state's insurance commissioner's office.
by Lori S
2 months ago
Asker's Rating: 
Other Answers
Your state insurance commissioner has more muscle than a lawyer. Just make sure that you can document coverage for those dates. Don mtnhealthinsurance ...
by Don- 2 months ago
I agree with Lori..the contract is between your ex employer and the insurance company. Do a three way call with both of them to see about getting this settled.
by Gummibear- 2 months ago
Your question is not likely to be answered in one word.find useful tips here though.health-insurance ...
by DONALD N- 2 months ago
You need to stop fighting this with the insurance company and agent. List the complaint in writing, with the letter of coverage dates from your employer, and the denial letters from the insurance company, and send it off to your state insurance commissioner. If it turns out that your employer messed up the benefits, with your dates, the commissioner will let you know, and THEY will then be responsible for what the insurance company would have paid, and THEN it's time to hire a lawyer. But it could jeapordize your job.
by mbrcatz17- 2 months ago