Hi I got Blue Shield ins. in March 2005 I set up an appointment for a for a check up because I hadn't been to the doctors in years. I mentioned that sometimes I get a pain in the upper right side of my abdomen so she sent me for an ultrasound to see if it was gallstones. that was around june 10th then about a week and a half later they called said I had gallstones and do I want to schedule surgery I said Id get back to her on that. July 4 2005 My gallbladder went crazy and I was admitted to ER to have it removed.
After that the insurance started saying they were investigating if its a pre existing condition. Then they paid the bills thought it was over now in Oct I get a letter saying that there investigating again saying that the medical records indicate that I have a history of gallstones ( I never was diagnosed until I went to there doctor) That I had a few episodes of abdomin pains in the past 2 years (which I had twice) and that I new I had gallstones and didn't intend to do anything about it. I guess refering to after I was diagnosed and didn't make an immediate decision. There wasnt even a month between the diagnosis and the ER room. Anybody no what I should do If I don't get them the info they want by 10-31-05 they said they might make it like I never had insuranse in the first place. Any advice The bills are over 50,000. I make 9.00 an hour Im very worried. I don't think I did anything wrong.
I hope U got your Ins. problem straightened out by now but thought I'd write
just in case. Yes, U R getting the run around. Go to Dr. &get copies of files
that show date being Dx. Then get copies from hospital regarding the need
for emergency surgery, the surgeons report & even anesthesia report + fol/up
Dr. copies. Unfortunately, U got a dits that entered things/dates in computer wrong & we know `They're Never Wrong'! Little joke. Anyway, keep fighting &
go up the ladder calmly saying I'd like your superviser, etc. Most Ins. co's
have an arbitration system' where you get to sit dwn w/ real people to show
the paperwk. Many times if U finally get to the right person for review, you
can fax the info w/ a short cover letter. It took me 2 yrs. to get a problem
like yours finally understood. The Dr's, names, dates comparison will show
you were insured at time Dx'd. Many people have to take the pain awhile till
they get family things in order or job. The law requires Dr's, hospital & labs
to give U copies after signing a release form. Hope U R better.
But how long have you had your insurance policy? By law, there is only a certain period of time where they can refuse to cover pre-existing conditions (no matter if you knew about the condition previously or not.)
Otherwise I would have your doctor that treated you for your previous stomach pain write directly to your insurance company. The stomach pain could have been from anything...and without a diagnosis, there is no way that you could have known your condition.
I'm an insurance agent myself (don't hate me!!!) But I do know the laws that insurance companies have to abide by. I'm really sorry that this is happening to you....
If I can be any help my email is ( removed - no emails - please read and follow the posting rules - anonymous on*the*boards sharing only ) I really hope this works out for you. Fight it as much as you can, you have the right to.
Last edited by moderator2; 11-03-2005 at 07:00 PM.
Hello Locca. You might be the person to ask my question. I have insurance that doesn't have the pre existing clause. I got hurt at work and have been dealing with w/c for 15 months now and they won't approve anything. Can I go to my own doctor that is the same doctor w/c sent me to? I need help with this maybe physical therapy,traction, something. My lawyer keeps asking me if my insurance will pay and I don't know if they will since i'm on w/c but they stopped my checks so all they do is pay for my doctor visit once a month. they even stopped paying for my meds. I just want to get better and maybe my lawyer can fight w/c to pay my insurance back. Just asking.
I don't deal much with Workmans Comp because I specialize in small businesses and self employed people. But hopefully I can help you at least a little.
Workmans Comp laws vary from state to state and there are restrictions on how much they will pay (of course.) But from what it sounds like, they haven't paid you anything yet, correct? Did they give you a reason why they would not pay your claims?
Have you told your employer about your difficulty in dealing with this? Has your employer offered you any compensation related to your injury?
I apologize for all the questions....it's hard to make a call on something without knowing the circumstances. I would suggest contacting you insurance company and telling them your situation. If you can get them to pay your claims until you get the WC situation worked out. Unfortunately, situations like this can get ugly. I would maybe talk to your lawyer about sueing the responsible parties.
Also, did this injury cause you any sort of pernament disability? Are you still at that employer and able to do your same occupation?
Hopefully I'll be able to help you out. Like I said, I don't deal with WC, but I still had to study the laws and regulations of WC when I went for my license. I'm more than happy to help you any way I can. Maybe if I get a little more information I might be able to come up with some more answers.
Hello Locca. Thanks for the response. I got hurt while trying to hold up a patient that was at least 300lbs. My arm went numb and the MRI showed 2 herniated discs in my neck impinging on my spinal cord. and a herniated disc in my back touching nerves. Every thing was fine until the neurosurgeon said it needed surgery. w/c would not approve an appointment for 4 months. Then the doctor set me up for the surgery and w/c denied the surgery. They sent me for 3 epidurals and nothing helped. Then they sent me to another neurosurgeon and he also said surgery and he said and even signed an affidavit for my lawyer saying if we wait the nerve damage my be permanant. They denied the surgery. They keep using the excuse that because I had surgery in the early 90's that it was already that way. I worked for a year and a half 10 hours a day without ever calling in sick. and they had me take a physical before they would let me start work to make sure my back and neck was not going to be a problem. and if the lady hadn't started to fall we wouldn't be talking about this. This has been going on for 15 months. I told them all I want is to get back to work. Well 5 days after my surgery was denied and I had already had my preop done and everything. w/c got a doctor to say I could go back to work while my doctor said no work until after surgery. I can't even drive on all the meds I'm on. can't sit stand or walk for long without having to lay down. most of my day is in bed. anyway I didn't go to work on the day w/c told me so they canceled my benifits. My doctor couldn't believe they did that because they knew I needed surgery to take the impingment on my spinal cord. My right arm is always pins and needles and the nerve pain is killing me. I just don't want my arm to get worse and my neck feels like another disc might be going because my little finger on my left hand went numb. Sorry this is so long but wanted to give as much info as I could so maybe you can give me some ideas. thanks again.
now I have to go lay down.
Sorry it took so long to get back you. This seems like a pretty sticky situation. My best advice would be to talk to your lawyer about the possibilities of suing to get compensation for your injury. You also could look into getting disability because you aren't able to perform your job any longer.
I really wish that I could give you a simple solution, but I think this situation is going to require drastic action. I would seriously ask your lawyer about all your options. I do know that Workman's Comp can deny a claim if the injury is over 2 years old. I know that you have already made claims, but they might use it as a loop hole.
I wish you all the luck. I think you should really take things to the next level. Unfortunately, I think it might be the only solution.
Thanks Locca, I called my lawyer today to ask if i can have anything done on my own. They are going to call me back. I really don't know how much longer I can play their game. My health is at stake here and I don't want to be where I can't use my arm. I can't get disability because I was a stay at home mom for to many years and after I got divorced and started to work again I didn't earn enough credits in the time to be able to get disability. I'm trying to get SSI but not holding my breath. I applied for food stamps but was turned down because my fiance made to much money. They didn't take into account that we pay out twice as much a month in bills as he makes and we have to borrow money to pay the bills. He pays 100.00 a week just for my health insurance. I wonder if I were in jail would they fix my neck or make me suffer like I am now. I feel like i'm on house arrest anyway.