Life or death situation need help - Health Insurance Issues Message Board

confusedgrl2 · 08-19-2003, 07:05 PM

Hi, I am 22yrs old and I have a heart disease called cardimyopathy, I also have hypertension, asthma, and sleep apnea. All that is bad enough, but too make matters worse I am about 170lbs overweight with a BMI of 54. For all of you who know what that means I'm sure you can see how bad that is. Since I got this heart condition in 2002 my health just seems to be getting worse and worse. I can't even do mild exercise without my heart rate going over 200, wich is bad in the first place, but when you have the kind of heart condition I do it can be fatal. All of my docs say i need to lose weight or I am going to die. I have a specialty doctor for each one of my conditions plus a pcp and they all recomend that I get the Gastric Bypass surgury. My health plan does cover it as long as it's considered a medical neccesity, and you have a 12 week documented failed weight loss attempt. So as soon as I found this out I went and enrolled in weight watchers and was in there program for 16 weeks w/no success. By the time I had gotten all the mandatory test and doctors refferals, it was 2003. They didn't send my request for the surgury in till around June. I then found out that as of January 2003 the mandatory docummented failure attempt had gone from 12 wks to 26. So they of course turned down the surgury. In cigna they have 2 appeal processes and if they still deny it you can have an external review board take over the case and make a decision. Well I have already sent in my first appeal and they denied it right away, now I have to send in 2nd appeal, each time your supposed to send in new information on why you think they made the wrong decision. and each appeal gets looked over by someone new. Well I'm really fed up with the whole thing, but I have a 5 yr old and a 1 and a half yr old that need me around. So if anyone out there has gone through something similar or has any advice on how to make a better appeal I would love to hear any suggestions. Just to make note - Cigna is absolutley the worst insurance company, I don't see why they have to make everything so complicated. Thanx for any replies

Mishaken · 08-19-2003, 07:51 PM

First things first, read the policy again. Every time I read mine I notice something different. Then call your state department of insurance and talk to them about your particular situation. There may be legislation in your state that requires your insurance company comply with their time frames or emergency needs. Your policy is a contract between you and the insurance company but state legislated mandates rules over that contract!! They are great folks and they will tell you if you have any rights that might apply and they will make inquiries on your behalf.

If need be file an official complaint with the department of insurance. It affects their rating in the state and goes on their public record. I filed a complaint on my company today for failing to process claims more then 5 months old despite repeated requests and making sure they had all the information they needed. They complained they were understaffed and I told them my provider was underpaid. When I looked up their history at the State Department of Insurance website I found that they have escalating numbers of complaints over the last 3 years and that the state even fined them $250,000 last year for failing to file claims in TX in a timely manner. That relieved all my guilt from filing a complaint.

I went through a situation with my own insurance where they insisted my policy said one thing (which it did) but I insisted that the State of Texas said something else. I finally won the appeal but it took about 4 months. It was worth it though.

Sadly your insurance company will not tell you more than what is in their own best interests. You have to be very proactive in learing whenever you can. You might even try to find an attorney who specializes in insurance appeals. Your state Bar Association can make some recommendations for you.

Good luck and let me know if I can be of any help.