Will Never Claim Ignorance

| San Antonio, TX, USA | Working | April 16, 2014

(My daughter has had an insurance claim denied due to pre-existing conditions. She had an allergic reaction to a routine vaccination she had the previous day. I work as a claims processor for the company we have our insurance through. I even process employee claims on occasion, and I know all the rules and regulations for pre-existing conditions as they apply to our insurance plan. I call the company to find out why they denied this claim.)

Me: “Hi. I’m calling to find out why you denied my daughter’s claim.”

Customer Service Rep: “Okay. It looks like it was denied for being a pre-existing condition.”

Me: “Yes, I know it was denied as a pre-existing condition. I’m trying to figure out why it’s a pre-existing condition. You see, I also work for this company and process claims like this on a daily basis. I know that there are certain CPT codes that are supposed to be looked at for pre-existing conditions. I also know that before a claim is denied for being pre-existing, the processor is supposed to research through the member’s history to see if there are any related claims that have been denied or paid or have documentation attached to prevent denial. I also know that if the processor had done their job correctly, that they would have seen a routine doctor’s visit the day before and would have made the connection between the vaccination and the allergic reaction. Plus, I also know that allergic reactions are not considered pre-existing when there are no other claims in the member’s history for a similar reaction. And now, the most important point: according to California law, pre-existing conditions can only apply for the first six months a member has a plan with a health insurance company. I have been employed by this company, with full benefits, for over a year and a half. There is absolutely no reason that this claim should have been denied.”

(There is extended silence.)

Customer Service Rep: “Oh. Okay, we’ll get that fixed and paid as soon as possible!”

(The claim was paid and I never had a problem with the company denying any claims for pre-existing conditions again!)

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