Insurance Issues

[Toogoofy317]

Maybe someone can answer this question. If insurance is changed by your employer and you are in the middle of treatment can the new insurance company deny you treatment

I was in the middle of cardiac rehabilitation when Disney decided they did not want to use Aetna anymore. Unfortunately, I was given the wrong information from the hospital stating that my referral would still be good. Boy were they wrong. Any how at first the hospital asked me if my insurance company could back date it. I tried and they said it would have to go through review but I could not have treatment until it was decided. The hospital said not to worry about it since it was their fault. They said they would pay for that month's treatment. So they said just get a new referral and tell Cigna that you would pay for that month's treatment. Cigna will not retract the review and they said it could take months to do the review. But in the mean time they cannot process the referral so I must stop treatment. The hospital is very nervous about that because they cannot get my heart rate stable enough for me to exercise on my own. They don't want to be responsible if something happened to me exercising without proper supervision.

I guess this is another example of insurance companies making the decisions that doctors should be making.

Sorry for my venting but I don't know what to do!

Mary S.

[sueb]

Insurance woes

Mary--This may be a case where you should contact the Insurance Commissioner in your state. Your insurance company is being unreasonable and this is threatening your health. Many states have now instituted a consumer complaint system to deal with these issues--I hope Florida is one of them.

Sue in Maryland where we have a wonderful Insurance Commissioner

[Sarah]

evil CIGNA

Dear Mary,

The Health Insurance Reform Act of 1996 precludes insurance companies from denying coverage of pre-existing conditions if you have been covered by insurance for the previous year. Since you are an employee of a company that changed insurance companies --you have not had any drop in your coverage and the new company has to honor your coverage for pre-existing conditions.

Continue your treatment and call the state of Florida and report CIGNA and have the Disney HR department drop CIGNA a little note letting them know they are going to cover your treatment or else talk to the lawyers.

Let us know how it goes... and hang in there!

Sarah

[Rich Miller]

I am not a 100% sure but I believe teh way the pre- exusting condition works is if you have had insurance coverage up threw the time you change over, that would go back far enough back to surpass the waiting period, then they should cover you right away.So in other words if you have had coverage for a while on current plan new plan should alsom cover you just dont let your coverage lapse!! I believe this is a federal issue and not something that change state to state.Good luck Rich

[Lisa Salberg]

Pre-exsisting conditions clause simply means that you can have treatment for the condition...HOWEVER the policy has to have coverage for the "procedure" if the new plan will not cover cardiac rehab then they are not required to. DOUBLE HOWEVER< I do not think that is the case - as rehab is on most plans.
1. Write an appeal to the new ins. company.
2. get a copy of the "PLAN DOCUMENT" for the plan - you want to check to see if coverage is in place for rehab. (you can get this from the HR/Benefits dept)
3. Talk to the hospitals billing people - explain that you are in appeals with your ins. plan and that you really need rehab. They may very well allow you to continue.
4. BREATH!
Lisa

[mjesaitis]

From my experience, Disney's CIGNA insurance is probably not saying that you cannot be covered for your rehab. However, they are most likely saying that since you can get the "same" rehab/treatment here in Florida (in their network), there's no reason to go out of state (out of network). They, like most doctors here, don't understand HCM so they don't understand the special care we need.

I ended up paying 100% for my trip to see Dr. Maron in Minn. after filing and losing two appeals. I bit the bullet because in my case, it was really just a one-time deal since I don't need all the maintenance follow-ups. But in your case, a lawyer might be in order.

I'm sorry you have to put up with their BS Mary. As you can tell, I don't really have any advice for you. I just hope you can get what you need.

Take care, Matt

[Toogoofy317]

Yes, Florida Hosptial is being really great about all of this because it was their mistake that got me into all of this. Cigna does cover cardiac rehab. It is not the problem of if they will cover it it is when. My problem is getting them to retract the back dated referral and just start over. Florida Hospital is eating the bill for that month. The rehab nurses are doing their part by not filing it. They said they would continue seeing me until they thought I was stable enough to do this on my own.

One good thing is that I qualified for charity at Florida hospital so they will help with a lot of my bills. I guess that is a really good thing and I should be excited. But in another since I feel a little depressed because I was still working full time hours at Disney and still qualified for charity. What is wrong with this picture. Sorry for the mild pitty party but it really got to me!

Mary S.