Health Insurance Carriers Declining People and Not Saying Why?

Jan 12, 2009

  1. riskybiz
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    riskybiz Super Genius

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    Are health insurance carriers obligated legally to inform a client why they are declining an application specifically?

    I have a client who was declined because of an abnormal pap smear. We submitted information to underwriting from her Dr. stating that she has not had a bad pap smear and Coventry one is still saying that they are declining her due to a bad pap smear.

    The only deduction I can make is that the carrier does not want her for some other reason for which they are not telling us.
     
    riskybiz, Jan 12, 2009
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  2. Crabcake Johnny
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    Crabcake Johnny Guru

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    The carrier must tell the client the reason for the decline - but just the client - not the agent.
     
  3. riskybiz
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    riskybiz Super Genius

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    Yes I should have been more specific. The company is telling the client via a letter that she is being declined for abnormal pap smears. Her Dr. submitted info saying that she has not had abnormal pap smears.

    So what options do they have? Go to the department of insurance?
     
    riskybiz, Jan 12, 2009
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  4. Crabcake Johnny
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    Crabcake Johnny Guru

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    Your client can file an appeal and remit any records showing that there was no abnormal pap.
     
  5. moonlightandmargaritas
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    moonlightandmargaritas Guru

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    Sound like there may be a difference of opinion as to what constitutes an "abnormal" pap smear.
     
  6. Crabcake Johnny
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    Crabcake Johnny Guru

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    Out of my experience? 99% chance the carrier is right - 1% chance the client is right. When it's all exposed that's when you hear...."Oh...THAT pap test, you see the reason for those results were..."
     
  7. moonlightandmargaritas
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    moonlightandmargaritas Guru

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    Exactly.

    I mean really, what would be the interest of Coventry (or any other carrier) to decline someone without a problem? They're pickin' on 'em?
     
  8. Crabcake Johnny
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    Crabcake Johnny Guru

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    I used to love that stuff:

    declined do to stress test:

    Client: My results were 100% normal - nothing wrong!

    Me with the carrier: Sorry but he is declined due to the results of his stress test but that's all the information we can give

    Me to client: You have your records? Can you fax 'em?

    Client: sure - give me your fax number

    Me to client after reading test results: Says here you have an undiagnosed irregular heartbeat.

    Client: Oh that? That doesn't bother me. Yeah, they wanted to put me on this med but I ain't going on no meds since I'm fine.
     
  9. riskybiz
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    riskybiz Super Genius

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    Normally I would agree with you, however the Doctor sent the supplemental records to me, including her pap smear results from 2000-2008 and additional colposcopy report ( more inclusive pap smear type test) which alll came back normal.

    The original decline stated that they were declined due to abnormal pap smear results, we appealed ,provided the additional information and they sent the same letter again.

    I know they ordered medical records and it was the same Dr. that sent the additional information stating there were no bad paps.

    So what do you do in this scenario, let her have a decline on her record for something that isn't true?
     
    riskybiz, Jan 12, 2009
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  10. moonlightandmargaritas
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    moonlightandmargaritas Guru

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    Not trying to be argumentative, trying to understand the situation, but here's my question:

    Why would she need a "more inclusive pap smear-type test" if her original was "normal" and unremarkable?
     
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