Reason for Claim Appeal

Our customer had a cough that grew worse, and on the fourth day, they went to the emergency room. They were diagnosed with pneumonia and admitted to the hospital. The customer had pre-existing conditions of Type 2 diabetes, hyperlipidemia, and a pacemaker.

Upon submitting the medical expenses to insurance, the claim was denied. The reason given was that the policy's certificate wording states that medical emergency care must be received within 72 hours of the newly diagnosed sickness or injury, and four days had passed without treatment. The company also cited the customer's pre-existing conditions. That is when the customer called Insubuy for help.

After Contacting Insubuy

Our Claims Resolution Specialist (CRS) reviewed the medical records and the policy's certificate wording. It was clear that claims department's information was incomplete; they thought they had all of the medical records, but they didn't. The fact was that 72 hours had not elapsed between the diagnosis of pneumonia and the beginning of treatment. Four days had elapsed between the onset of symptoms (a recurring cough) and the customer's decision to seek treatment at the emergency room. Only one day elapsed between the pneumonia diagnosis and the customer's admission to the hospital for treatment.

Our CRS went on to coach the customer on how to write an appeal stating that a cough is a symptom associated with many conditions, ranging mild to severe, and should not have been considered the clear onset of the primary diagnosis of pneumonia. The CRS advised the customer to argue that unless the claims department could prove within reasonable medical certainty that the cough was directly related to the pre-existing conditions of diabetes, hyperlipidemia, or the pacemaker, and not to the new condition of pneumonia, then the insurance company ought to reconsider all claims in question. Two months later, the denial was overturned, and all claims were paid.

Conclusion

The same visitors insurance is available at the same price from hundreds of websites. It is important to purchase from a broker with a solid history, knowledge and experience within the industry, and a willingness to help customers who run into any legitimate claims issues. Some customers might mistakenly believe that every broker is eager to help customers with such problems, but unfortunately, that is not true. Too many brokers will leave you alone to deal with claims yourself once they have sold a policy and made their commission.

As part of their commitment to stellar service, Insubuy representatives always work as their customers' well-wishers and try their best to help them. Claims resolution is a service that we offer at no additional cost to the customer. If you feel that your insurance company wrongly denied a legitimate medical claim, please reach out to us. We guarantee that we will investigate to the best of our ability and assist you if we discover that the insurance company was, in fact, in the wrong.