The following is the introduction portion of my first Appeal to "Insurance Company"
to reverse their decision to deny the butt-load of bills I have from all the recent medical hoorah. The following will stand temporarily, with the name of my insurance withheld in case it affects my appeals process. I have just this past Saturday received the denial of my first appeal attempt. I have one more internal, and then a Federal External appeal to go. trust me... if I end up paying, I'll let ya know the name of the *%$#@ers who pulled this crap, and I'll do it loudly.
We live in a complex age, the age of information. As a matter of fact, in some ways we live in an age of too much information. Google “information overload” and you are immediately overloaded with information: more than 7m hits in 0.05 seconds. Some of this information is interesting: for example, that the phrase “information overload” was popularised by Alvin Toffler in 1970. Some of it is mere noise. But it seems certain that there is too much information for the regular citizen to be aware of everything that is pertinent to their lives.
Civil liberties lawyer Harvey Silverglate estimates that the average person unknowingly breaks at least three Federal criminal laws every day. Federal crimes!
If you use an iPhone or an Android based smart phone, then you have likely on the regular acceded to all sorts of things that you may not be aware of when you “agreed” to the terms and conditions just to be able to activate the device. Most people don't read what they are agreeing to, they simply assume that there is nothing untoward or unusual in what they are agreeing to. They assume that they would hear through their fellow citizens if there was anything too burdensome or bizarre.
If you use an iPhone or an Android based smart phone, then you have likely on the regular acceded to all sorts of things that you may not be aware of when you “agreed” to the terms and conditions just to be able to activate the device. Most people don't read what they are agreeing to, they simply assume that there is nothing untoward or unusual in what they are agreeing to. They assume that they would hear through their fellow citizens if there was anything too burdensome or bizarre.
When it comes to insurance, I have a basic understanding of what would and would not be covered. When I wasn't sure if Bariatric Surgery would be covered, I called the phone number on the back of my "Insurance Company" card and had a conversation with a representative. Before the conversation occurred, I was informed that the call would be recorded, and apparently it was. I mention this because it is important to know that my recollection of the conversation lines up with what was said, and more importantly what was not said in that recording. I assume you, the reader, will look up and listen to that call the same as has already been done by my client representative for Blahblahblah Insurance. You will hear me ask about my coverage for Bariatric Surgery and discover that it was not covered. You will hear me then ask if went the self-pay route, whether any of what I paid would be able to be applied to my deductible. I was told “no,” but nothing past that. Not one single mention of the very pertinent information that any and every complication from any self pay procedure or surgery would also not be covered by Selecthealth until a year had passed.
You will hear me weeping in disappointment and frustration by the end of the call, and it is possible that the representative didn't want to give me any more bad news in that phone call.
I can assure you, I would much rather have heard the full facts in that phone conversation, as opposed to when I heard them, looking at the first denials of coverage of hospital bills, after the fact.
I was well aware of possible complications to the Gastric Sleeve surgery, I did after all, do my homework. In addition to doing my due diligence, I had eight years earlier, watched as an acquaintance had the VSG surgery, and found herself a little over a week later in the ICU for a month, with a leak. Her leak was especially bad, and very nearly killed her, and had she not had insurance to cover the bills, it would have ruined her family financially.
Because of the failure of "Insurance Company" to inform me of the grave financial risk I was taking, when I asked them about self pay surgery in the phone call, I made a decision I would not otherwise have done.
It did not occur to me that such a policy was a possibility, and because of that lack of knowledge, I made my decision in good faith, thinking I had the best information from "Insurance Company". Like any modern American I trusted that the insurance company with whom I had a relationship and reasonable expectation of fair treatment, would have informed me of such a huge financial risk when I was actually asking questions about it on the phone.
Because of the informational vacuum in which I made my decisions, I did go and get the Gastric Sleeve surgery on October 22, 2018. Interestingly, had I waited just a few months, I would have been covered by "Insurance Company", as apparently January first of 2019 the policy of not covering complications to surgeries not covered by "Insurance Company" has changed.
The point to my appeal, is that even though it is apparently in my policy that "Insurance Company" will refuse to cover any and every complication for the Sleeve surgery that I’d had done, that I was treated unfairly in that this vital information was withheld from me. There was simply no other reasonable way for me to know of that policy if "Insurance Company" refuses to inform me of it when I call and actually ask for information about self pay bariatric surgery.
If that is something that cannot be done, then I request that the new policy as of January first, of covering complications, please be extended two months to retroactively cover my situation.
