Pregnancy health insurance claim denied, what can I do?

I made a trip to the ER a few months ago, and to our shock the few hours that we spent there, along with tests performed and follow-up dr. visits, ended up costing over $8,000. The only thing wrong with me was that I had an unexplained rapid heart rate, which ended up being due to me being pregnant. My insurance company is supposed to pay 80% of all claims, but is now refusing to pay beyond $3000 of this claim. Reason given is that they have a cap per each emergency "condition" unless there is surgery involved. However, there is no such cap on pregnancy-related claims. All pregnancy-related claims are paid at 80% no matter what. Still, they are categorizing the rapid heart rate as a "condition' rather than pregnancy thing. All tests showed no "condition" other than pregnancy, and all drs agreed that this was related to me being pregnant. Does anyone have any idea what recourse I have for this? What chance to I stand if I challenge them in court? Anyone with first-hand experience doing this? We live in Illinois. Great responses so far, thanks so much! The other part of this is that I cannot imagine how my ER bill alone was over $6,000. Yes, I was hooked up to monitors for a couple of hours, they did some blood tests and ONE scan of my heart. I talked to an actual dr. for 5 minutes, then they released me because my heart rate was back to normal. I expected to have maybe a $1,000 bill max, and insurance would pay 80%. Sad to say, I will think long and hard next time something odd is wrong with me before I visit an ER again. This is a huge blow to us financially. sarah314, thanks for your answer. Now they are telling me that all my ER expenses except for a tiny misc. ER amount are considered "outpatient treatment" and are subject to the $3000 limit. Yet they show benefits for hospital ER as including "staff physician, us of ER supplies, necessary emergency treatment" as being paid at 80%. The policy is confusing, and so far nobody will tell me how to protest the claim.

9 months ago - -4 answers