I had a colonoscopy done because I was feeling nauseous and couldn’t keep my food down. The doctor thought it might be IBS. My insurance company agreed that this was a covered procedure as long as there is no pre-existing condition which there wasn’t. Now they are saying I owe them about $7500 because the doctor found minor internal hemorrhoids and that is one of the items not covered within the first 6 months of me being insured. My question is, I didn’t go to the doctor because of hemorrhoids (I’m not bleeding or ever had any symptoms and was NEVER a concern), I went because I was sick and couldn’t keep my food down. So how can they be denying the coverage when I didn’t even know that’s what they would find? Shouldn’t they cover you based on the initial visit diagnosis and the reason why you’re having the procedure in the first place? The doctor found internal hemorrhoids which 98% of us have – they’re benign and not "a condition." They do nothing. The doctor says that was the diagnosis and the outcome of the procedure so that’s how they report it. The insurance company says, sorry, we told you hemorrhoids weren’t covered. And I’m wondering how it is that I went in for a supposed covered procedure because I was just sick in my stomach and came out owing almost 8K. Anyone ever heard of this?!?! I’m very concerned…:confused::mad::confused:

Ins. co. will do/not do and say anything to get out of paying for treatments.

In the first place the ins. had to be contacted prior to the scope to have the procedure pre certified based on your GI's recommendation and observations. You would not have been able to go ahead and have the procedure if it was not pre-certified. So they were well aware of your digestion problems.

That being said. Call them up and log the date time and name of the person you spoke to. Tell them what went on and that it was never previously diagnosed. See what they say, if that rep gives you no help (because they are taught to speak from a script) say thank you and you want to speak to their supervisor. If you get nowhere with the supervisor then write a stern and to the point letter of appeal. Reiterate the conversations you had over the phone. Remind them that they did approve the procedure prior to it being done. Explain the reason your Dr., ordered your scope and that "While they were in there" they discovered previously undiagnosed asymptomatic internal hemorrhoids. (they know why the Dr. prescribed the test, they demanded his opinion as apart of the procedures pre-approval process)

Send your letter with a copy of your chart from the GI Dr. it should clearly say newly found... further state that you are well aware of the term limits of your coverage however, this was an initial diagnosis and should not apply.

Send your letter certified, return receipt requested. Follow up on the phone when you get the receipt in the mail. Be prepared to appeal by letter more then once. Do not pay a penny untill you have exhausted every level of appeal and then have consulted with an attorney. Good luck and be tough!

Need some more info:

1) Have you ever sought treatment for this before (meaning the past 6-12 months)?
2) What was the primary diagnosis code that your physician put on the claim? If this was found from a diagnostic colonoscopy for IBS, the hemorrhoids should have been coded secondary.
3) What insurance company is it?
4) What's the specific wording of your contract regarding preexisting conditions?

It's to bad wealthy people keep stealing money from sick people. I hope you can get this taken care of.