Health Insurance

Have you ever been denied coverage?

By Annette Beach

Why is it I can be strong and stand up to any person or challenge that comes my way, but when I have to deal with health insurance representatives, I drop to my knees in tears?

When we pay premiums for health care coverage (regardless if it’s through an employer or a private policy), we are given the impression the insurance company is on our side. But are they?

For the past three months, I have been dealing with a health issue that requires extended treatment and surgery. Because of the seriousness of my condition, my local doctors and surgeons have suggested that I seek care at a tertiary center in another state. 

When I called my insurance company to discuss benefits, I was told by a benefit coordinator that if the procedure is medically necessary, it would be covered. After I explained the circumstances, the benefit coordinator decided it was not medically necessary for me to leave the state and I was denied coverage.

I continued to explain how my doctors felt I would benefit from the experience of the out-of-state surgeon and if I didn’t get a surgeon with his qualifications, the outcome would not be in my favor. In a stern voice, she said, “There are qualified doctors within the area who can perform the necessary surgery. Surely you can find a qualified surgeon who is ‘in network.’”

I proceeded to tell her, “The surgeons who are ‘in network’ are the ones referring me to the surgeon who is ‘out of network.’” She refused to hear more (and implied that I was trying to get a free vacation out of the company – at a hospital), and again denied coverage. 

Realizing this was a lost battle, I inquired about filing an appeal. This must have insulted her because her tone became even more hateful and she began to recite my policy terms in a monotone. When I asked for clarification, instead of explaining, she read it again. 

How can a benefit coordinator justify denying medical care when she does not know my medical history? And why wouldn’t the insurance company trust the opinions of the doctors who are in their network?

This is not the first time that I’ve had to fight for medical coverage and I’m sure it will not be the last. It’s sad to think that someone sitting at a desk, answering a telephone has the power to decide my medical needs over those who have been to medical school and have followed my history for more than a decade. What’s worse is I pay premiums to a company that employs her and she has the nerve to make me – the patient – feel like I’ve done something wrong.

Have you been denied coverage? Did you file an appeal? If you have had issues with your health insurance, please share and tell us how it made you feel or how it ended. Do you have tips that can help?