• Insurance Carrier: American Community
  • State: MI

Consumer Complaint:

I had terrible pain in my legs. In the morning I could hardly walk because of the shooting pain. I was referred to Dr. Keller, a nuerosurgeon. He believed the best way to relieve the pain was to use an X-stop device. The Doctor’s office called my insurance company with the codes for this surgery and they reported that no pre-authorization was required. My surgery would be covered as long as I paid my $500 deductable, they would pay 90% of the costs.I had the procedure on 6/30/08. On 11/19/08, Dr. Keller’s office was informed the X-stop device was considered experimental and would not be covered. My grievance is that we were told the procedure was covered, and the X-stop device is FDA-approved. I contacted the insurance company and set up a phone group interview with the grievance committee. They wrote back and denied my claim. I had paid about $1700 a month for almost 10 years to this company. Before they denied my claim, they upped my premiums to $2,250 per month! This was for 2 adults and 1- 19 year old collage student. We were forced to get new insurance. I can’t afford to pay the bills that they denied.

Insurance Expert Answer:

Let's separate the long term history (at best it's a tie-breaker) from the operative facts and take out the emotion. There are 2 issues -- is the procedure you had regarded as experimental or not? Your doctor can assist you in getting that data.

May the oral okay you received be regarded as definitive? If your policy was obtained through a private sector employer it is covered by ERISA. Try to get your employer's benefits office to go to bat for you. Continue to pursue your appeal, and be very careful of deadlines, as you may have to sue the carrier and can do so (under ERISA) only after your administrative appeals are exhausted. Deadlines are strictly enforced.

The fact they told you it was okay on the phone will be more helpful in litigation than it will be with the carrier, as the carrier will claim they have a standard message that they play on every call to the effect that the terms of the policy govern and the company is not bound by information provided over the phone.