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Denial of coverage question?

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Old 03-27-2011, 05:41 PM   #1
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Denial of coverage question?

My son has had problems with vomiting and a month ago anemia. He applied for insurance and they denied him saying he had ulcers. In fact, he had an endoscopy and there was nothing, no ulcer, nothing.

Unfortunately, the day before he received his denial, he had to go to hospital and they diagnosed him with pancreatitis.

This was the first time, he was ever given any other diagnoses other than IBS. Can he be denied coverage for something he was not diagnosed with when he applied? I understand them not covering any GI related problem for a year, but to totally deny coverage to him for an ulcer which he did not have?

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Old 03-28-2011, 10:03 PM   #2
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Re: Denial of coverage question?

If denied coverage ask the insurance company for proof of the reason - you want to see the actual documents that led them to the decision. Often it's based on notes such as "patient was seen today for gastric pain, may be ulcer" and then the insurance company sees the possibly treatment/diagnosis of an ulcer. And then if he was given a medication to take for ulcers, but later it was found not to be an ulcer, that makes it even more difficult.
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