WWTBAM Bored

Since you seem to have a handle on insurance stuff, would you mind advising us on this one?

#2 son fell on the playground a few weeks ago. Knocked himself out cold, as he hit the concrete face-first, running full speed. Idiot teacher on playground duty picked him up and moved him, but that's not really germane.

By the time my wife got there, he was conscious and talking. School nurse wanted to call an ambulance, but after consulting with our pediatrician, we decided to take him there instead. She drove him to pediatrician, then took him to referred hospital for precautionary CAT scan. Now we're getting notices saying insurance won't pay for CAT scan because "prior notice was necessary, and not given."

Is this usual? Or is this too far out of your field?

mrkelley23 wrote:Since you seem to have a handle on insurance stuff, would you mind advising us on this one?

#2 son fell on the playground a few weeks ago. Knocked himself out cold, as he hit the concrete face-first, running full speed. Idiot teacher on playground duty picked him up and moved him, but that's not really germane.

By the time my wife got there, he was conscious and talking. School nurse wanted to call an ambulance, but after consulting with our pediatrician, we decided to take him there instead. She drove him to pediatrician, then took him to referred hospital for precautionary CAT scan. Now we're getting notices saying insurance won't pay for CAT scan because "prior notice was necessary, and not given."

Is this usual? Or is this too far out of your field?

I'm not an expert, Mr.K. Though I was a claim adjuster for four years back in the day.

I would be so all over this company in a minute. There must be extenuating "emergency service" definitions. Plus, do they just not pay for CAT scans in general? This all sounds like someone stupid has looked at your claim.
Get the contact information for your state insurance/attorney general peoples.

Does being 5 hours late with a reply still count? How can you get prior approval for an emergency? I would most certainly appeal their decision.

I don't deal so much with the health stuff, more property and casualty (although I did handle a death claim last week) and all insurance companies are different. I'd be pulling out my benefits booklet as well. It is a good source of this type of information.

Let me know what you find out and we'll go from there.

Thanks, Beebs and Kay. Good to know I'm not completely off my rocker.

We've alredy fired off the first appeal letter, complete with color pics of his swollen, black-and-purple face. I hope someone gets dope-slapped for this, but the cynic in me tells me it's just another insurance company dragging out payments as long as possible, so they don't have to pay as much. I'm going to send a letter of complaint to mt Association representative and the school corporation. Maybe if they start lsing clients it won't happen so much to the next guy.

I'll keep you posted, and thanks again!

mrkelley23 wrote: I hope someone gets dope-slapped for this, but the cynic in me tells me it's just another insurance company dragging out payments as long as possible, so they don't have to pay as much.

I doubt it. Did you see the report on the news Friday night about the insurance company that gave bonuses to their employees who found sick customers whose policies they could cancel? (It was for stuff like not fully disclosing their medical history. Quick: list every doctor's visit you've had in the last ten years. Miss one and we'll drop your coverage. This was one of those themes mentioned in SiCKO, too.)

But, hey, you could always hold a bake sale to pay for that CAT scan.

Got the mail on Saturday. Among all the junk mail was a notice from the insurance company that they had paid for the radiologist to read the CAT scan that they wouldn't pay for.

Whatever.

mrkelley23 wrote:Got the mail on Saturday. Among all the junk mail was a notice from the insurance company that they had paid for the radiologist to read the CAT scan that they wouldn't pay for.

Whatever.

This is Mother Murphy's Law in action!

"Murphy's Law applies even to itself. That's why sometimes, somehow, usually when you least expect it, everything turns out right."