| TrailRunner67 |
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My health insurance plan started in May 2011 and everything was fine in 2011. I received infertility treatments and they were covered. At the end of the year, my insurance informed us that there will be some changes in 2012 and they sent a new Benefits Booklet. I sent an email asking if my infertility benefits will stay the same. They said YES. Here's the email exchange: --------------- Original Message --------------- From: [Me] Sent: 11/29/2011 4:21 PM Subject: 2012 Infertility coverage I'm currently enrolled in a PP1 plan. My member ID is XXX. I'd like to confirm 2012 benefits regarding coverage of: - Infertility treatments - Infertility drugs It was covered under my plan in 2011, and I want to be sure this will be covered in 2012. Regards, XXX --------------- Original Message --------------- Dear XXX, Your benefits for infertility treatment will remain the same. You can use our drug calculator to find out how the drugs will be compensated for next year. You can find the calculator here: XXX The glimpse of the certificate that you are listing is a limitation for new members who may not have had prior coverage. Best, Member Services XXX |
| Mr. Obvious |
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File an appeal of the denial and include your e-mail exchange for consideration. |
| TrailRunner67 |
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In 2012, I had more treatments and at they were processed fine. I just had to pay copays. But then I started to receive letters denying every benefits. Every letter gave a different reason: - Deductible - Preexisting condition - Benefits will start in May 2012 - Overage The most recent letter states that I'm overage. My DOB is 09/30/67. I'm 44 and change. The Benefits Booklets says that "Coverage is Provided for Individuals 21 to 44 Years of Age as of the date the services are rendered". Does my benefit end at 44 years and 1 day, or 44 years and 364 days? |
| TrailRunner67 |
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Mr. Obvious, thank you. I was wondering if an email was valid proof. I've also added other things. In 2012, they keep denying EVERYTHING. I keep receiving different reasons! It has been very stressful. Right now, I have $6,000 of claims that are denied, basically all my treatments this year. |
| bmcpool strikes back |
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Thanks to Obama and the Affordable Care Act, there should be more transparency to appealing denied claims. see here: http://www.healthcare.gov/law/features/rights/appealing-decisions/index.html it seems that it will also require some investigation into state laws, which the healthcare.gov website can direct you to. good luck! |
| Mr. Obvious |
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An e-mail confirming coverage would certainly be relevant evidence. I would also ask your doctor for a copy of all of their original billing documents and all correspondence they have received from your health insurance company. |
| Lola |
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You should have been coming to me. |
| next up |
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I'm not trying to be offensive or demeaning, just raising a thought question. Does it cost $6,000 to adopt? You're 44, if you want to do this, then let's get the child sooner than 40 weeks if it's at all possible... |
| TrailRunner67 |
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It costs more than $20,000 to adopt. It's a very long procedure and most likely we wouldn't be able to adopt a baby. The mother can change her mind, etc. To put it simply, I would like to have my own children with my husband and my doctor thinks I have a chance. |
| next up |
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Okay, thanks for your civil reply. Perhaps at this point a lawyer's letter could help make your argument. You're out more money right now, but it might save you from paying the $6,000. |
| The sea yields to knowledge |
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You should talk to a lawyer. Also, it's difficult to determine anything without seeing your policy and knowing what state you live in. |
| ughhhhhh |
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Here are 3 options. Call the insurance company and keep asking to speak with the person's supervisor and keep going up the chain until you get the result you want. Contact your hr rep or your husbands hr rep (whoever the insurance is through) and ask for help. They should help with plan benefits if the insurance is through the company. If the above things fail, call the state insurance commissioner of the state where the plan is administered from and file a complaint. Sadly, even if you have coverage doesn't mean they will be responsible for paying the bill. They always have loopholes. |
| insurance guy |
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The way it is worded, you would be denied at 44 and 1 day. same way with "children can stay on their parens until 26" in the ACA. 26 and 1 day and they're out. This is the most common. There are some "cadillac plans" that consider your increase in age to occur on the last day of the year, but you wouldn't be dealing with denied claims for routine treatments at all if you had on of those. |
| TrailRunner67 |
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Thank you, everybody. It really helps to have your input. Lately I've been unable to sleep because of the worries. Thanks again. |