The Evil of Insurance Companies

My God I hate these guys. Two years ago I had hemorrhoid surgery. My insurance is a subgroup of CIGNA. The doctors checked to make sure the procedure was covered by CIGNA, performed it, and all was well… until the bill came.

They refused to pay as apparently the APWU (my insurance) has a certain other restrictions beyond CIGNA. I ended up having to pay most of it myself because apparently this isn’t an important medical procedure and I get must just get ass surgery for fun.

Today (two years later) I get a bill from the anesthesiologist. The insurance had paid for them, but now they have apparently decided they don’t feel like it and are taking the money back. They didn’t bother to mention this to me though.

Oh, and to add insult to injury, the anesthesiologist is bumping the bill up to a higher level they charge private individuals over insurance companies.

My question is: how best do I fight this? How do I find a lawyer to handle this, and what procedures do I need to follow? Failing that, how do I find the home address of the APWU CEO and does anyone know where to get a good deal on napalm?

I suspect this will be moved to IMHO.

A good place to start in finding a lawyer is to see if your area has a lawyer referral service, usually run by your local city, county, or state bar association. Act fast, since you might start bumping up against time limits.

Virginia Bureau of Insurance

A friend of mine was late with his car insurance premium; had an accident several months after he paid; the insurance company refused to pay, because of the late premium.
“But you cashed my check!!”
– “Oh! … Here, we’ll refund it.”

I hope I don’t need to explain why this was utter fraud or larceny on the insurance company’s part.

If the anesthesiologist was in-network at the time of the procedure, I don’t think they CAN charge more than the contracted rate regardless of who pays it.

Definitely file a complaint with your state’s insurance commissioner, and fight like crazy. Insurance companies, in my experience, will mis-handle things where they think they can get away with it, in the hopes that you will get tired of arguing with them.

You may have passed your insurance company’s internal statute - I know my claims always say something like "you can file an appeal for up to 180 days - but it’s worth a try anyway. Especially since they paid the anesthesiologist initially.

In addition to Mama Zappa’s excellent suggestion to file appeals and running coach’s link to the VA Bureau of Insurance, I’d also suggest using name-and-shame if you don’t get any help, or if things drag on. Social media can be powerful.

If your insurance is through your employer, and your employer is self-insured, the HR folks who handle the insurance might also be able to help. They normally have a contact at the insurance company who works with the employer company directly. That’s also worth a shot.

Good luck.

I hope it doesn’t come to you having to pay him, but if it does, you can negotiate with providers. They’ve asked you for the private rate, but they know they’ll be lucky to get the insurance-negotiated rate. Use that to your advantage.

My wife is a licensed counselor and is a provider for many of the major insurance companies. She once had a story like yours happen to her, but her POV is from the other side. A guy came to her for counseling, she checked his insurance and got approval for 11 sessions. She saw him, billed his insurance, and was paid.

Now fast-forward one year later. My wife’s check from that same insurance company was several hundred dollars less than it should have been. With it was a letter explaining that they had looked into their records, and found that the previous guy should not actually have been covered, so the pre-approval was mistaken, and they’re docking what they paid her from her current payment. She ended up just eating the charges.

Two decades ago, when I was uninsured and paying the higher uninsured rates, and the liberals were killing health-care reform by “loving it to death”, I wrote my Congresscritters and newspapers to say that mandating same price for same service would be a simple way to help the uninsured, if that really were their goal.

The Know-Nothings bantered back that this would be overreach of Fed authority, a restraint of free trade. :smack: Any health-care reform is a restraint of free trade; the issue is whether Congress wants to actually help the uninsured or just keep fighting on behalf of its rich campaign donors.

Moderator Action

Since this involves potential legal issues, you suspect correctly.

Moving thread from General Questions to In My Humble Opinion.

Thank you all very much. the conversation with the insurer went as poorly as might be expected. The conversation with the doctor’s office is not going much better. Lawyer time.

I’d think it would be the insurance company bumping up against time limits. I mean, 2 years later? WTF? :dubious:

Hemorrhoid surgery and the insurance company was the pain in the ass? Maybe they just like irony.

If your employer is a fairly large company, the HR guy may be able to blackmail the insurance company with the threat of dumping them the next time open enrollment comes up.

It’s worth asking HR if they can help.

Yup. I’ve had this work in my favor.

Actually, insurers don’t want to lose ANY company, but they really do hustle when it’s a larger employer.

Is the insurer claiming that you misrepresented your medical history?

Sounds like a big hassle, true… but hey, at least you got to experience hemorrhoid surgery.

It seems to me like your issue is not with Cigna, but with the APWU (which I assume stands for American Postal Workers Union). If the employer/sponsor puts additional coverage restrictions in the contract, the insurance company is not at fault for abiding by those. It sounds like the Dr’s office called Cign and verified standard coverage and failed to/didn’t know to specify that you had APWU’s version.

I’d also be willing to bet that the APWU is self insured and only uses Cigna to administer the program.

This. APWU is a very very large government group (more than just postal workers) with a lot of special handling stuff that goes on. I’ve got friends and family that have that coverage. If you don’t call the special phone number for that account you’re going to get the wrong answers to your questions. It’s not simple coverage - there are a lot of complications and I believe it is an ‘administrative services only’ group from what I’ve heard from the folks I know.

Sounds like the OP is SOL due to coverage through the APWU.

I hate insurance companies. I’ve had a rash of “takebacks”, where they paid me and then a year or two later send a letter saying that they are taking back the money but they NEVER give a reason why. I can’t bill the patient because they were covered and I can’t explain to them why they have to pay and when I call the insurance company nobody seems to know why the money was taken back. I can’t rebill because too much time has passed so I end up eating the charges. There is a limit on how long the doctors have to submit their claims; there should also be a limit on how long the window is which the insurance companies have to take back their money.