Cigna, please pay me my money
November 7, 2010 8:26 AM Subscribe
If my health insurance company refuses to pay and I think they should, what next?
I broke my back skiing last year. Lots of pain. I had a choice to have wife drive me into town (~50 miles) or get painkillers at the ski area medical clinic. Actually called Cigna (insurance provider), they said no problems $50 copay its an emergency, go to the clinic.
I paid the bill in full there ($380), and for a year now have been trying to recover the bill-ex-copay. For a year it was "the check is in the mail" - literally, now they just say "no" for a bunch of reasons I have no idea like "ammendment-35".
What recourse does someone like me have here? It's not like I desperately need the money, but it pisses me off they will not pay when they said they would. It seems like hiring an attorney for this small sum is not worth it. Can I sue them in small claims court or something?
I broke my back skiing last year. Lots of pain. I had a choice to have wife drive me into town (~50 miles) or get painkillers at the ski area medical clinic. Actually called Cigna (insurance provider), they said no problems $50 copay its an emergency, go to the clinic.
I paid the bill in full there ($380), and for a year now have been trying to recover the bill-ex-copay. For a year it was "the check is in the mail" - literally, now they just say "no" for a bunch of reasons I have no idea like "ammendment-35".
What recourse does someone like me have here? It's not like I desperately need the money, but it pisses me off they will not pay when they said they would. It seems like hiring an attorney for this small sum is not worth it. Can I sue them in small claims court or something?
You might get some help from your state insurance regulator.
Small claims court may be an option as well. When I sued my insurance company there, I implicated the RICO act and sought triple damages.
I am not your attorney and this is not legal advice.
posted by exogenous at 8:32 AM on November 7, 2010
Small claims court may be an option as well. When I sued my insurance company there, I implicated the RICO act and sought triple damages.
I am not your attorney and this is not legal advice.
posted by exogenous at 8:32 AM on November 7, 2010
IANAL, IANYL, etc., etc. Read your policy. Somewhere buried deep inside is the procedure for filing and processing an appeal. Follow that procedure. If you do not get satisfaction, file a claim with your state's insurance commissioner. While you are reading the policy check whether they have an arbitration clause. If they do (most likely) you are probably prohibited from filing suit.
You do, of course have a written record of all of the "approvals" they gave you by phone? Notes as to who said what, when, etc. Make copies of these notes along with copies of all of the notes you made when they told you "the check is in the mail." This is your proof that they are dealing in bad faith. Send these along with a demand letter to them with a copy of all of it to the insurance commissioner. Demand that they respond in writing within "X" number of days. When they fail to do so, follow the appeals procedure and then reassess whether the time you are spending is worth continuing the process. If so, it is either arbitration or small claims court.
posted by Old Geezer at 8:46 AM on November 7, 2010
You do, of course have a written record of all of the "approvals" they gave you by phone? Notes as to who said what, when, etc. Make copies of these notes along with copies of all of the notes you made when they told you "the check is in the mail." This is your proof that they are dealing in bad faith. Send these along with a demand letter to them with a copy of all of it to the insurance commissioner. Demand that they respond in writing within "X" number of days. When they fail to do so, follow the appeals procedure and then reassess whether the time you are spending is worth continuing the process. If so, it is either arbitration or small claims court.
posted by Old Geezer at 8:46 AM on November 7, 2010
Seconding the suggestions by old geezer, read your policy closely, follow the procedure listed there, document everything and when your efforts fail, state insurance department, then small claims court is next. Make your insurance company send a lawyer down and if the fail to appear, hooray, they're now in default.
posted by Brian Puccio at 9:00 AM on November 7, 2010
posted by Brian Puccio at 9:00 AM on November 7, 2010
Best answer: I am an attorney and my SO works in the billing office at the hospital. Neither of us would recommend small claims court. Here is what we do recommend:
SO says that insurers will deny coverage for any reason or no reason at all. They'll also say things like "we didn't get the fax," or "I can't find the file," just to stall. That's what it sounds like is happening with Cigna's "the check is in the mail."
Your best bet is to call and be increasingly forceful regarding payment of your claim. They'll make every excuse and say all sorts of dumb stuff you don't understand (ie, "amendment 35"), but it's mostly just a ruse so they don't have to pay. Every time they say something you don't understand, ask for a detailed, plain-English explanation.
Particularly helpful to your case would be if you can get them to admit that they have record of your telephone call from the date of the injury. They almost certainly do, but an admission of such record will be more difficult to procure.
Also, continually ask to speak to a manager or someone with more power. Continue escalating any claims through the management chain - the higher up you move, the more likely you'll get paid. But beware - this is definitely easier said than done. You will have to stay strong and forceful (but not rude, you don't want the rep to shut down on you).
Of course, they'll say you need to fill out x form and provide x documents - go ahead and jump through their hoops, but follow up with them closely every time you send something their way (ex. "I just faxed over the billing records again, can you please verify that you received them?"). And any time you fill out a form or appeal a denial, be as detailed as possible, so they can't later turn around and say you didn't mention something before.
Finally, meticulously document every communication you have with them, including date, time, name of person you spoke to, and content of the communication. Use this information against them any time possible.
Phew! I'm exhausted just typing this. What a crock. Stay strong! I have been in your position and given up, which is just what the company wants. Best of luck to you.
posted by angab at 9:25 AM on November 7, 2010 [4 favorites]
SO says that insurers will deny coverage for any reason or no reason at all. They'll also say things like "we didn't get the fax," or "I can't find the file," just to stall. That's what it sounds like is happening with Cigna's "the check is in the mail."
Your best bet is to call and be increasingly forceful regarding payment of your claim. They'll make every excuse and say all sorts of dumb stuff you don't understand (ie, "amendment 35"), but it's mostly just a ruse so they don't have to pay. Every time they say something you don't understand, ask for a detailed, plain-English explanation.
Particularly helpful to your case would be if you can get them to admit that they have record of your telephone call from the date of the injury. They almost certainly do, but an admission of such record will be more difficult to procure.
Also, continually ask to speak to a manager or someone with more power. Continue escalating any claims through the management chain - the higher up you move, the more likely you'll get paid. But beware - this is definitely easier said than done. You will have to stay strong and forceful (but not rude, you don't want the rep to shut down on you).
Of course, they'll say you need to fill out x form and provide x documents - go ahead and jump through their hoops, but follow up with them closely every time you send something their way (ex. "I just faxed over the billing records again, can you please verify that you received them?"). And any time you fill out a form or appeal a denial, be as detailed as possible, so they can't later turn around and say you didn't mention something before.
Finally, meticulously document every communication you have with them, including date, time, name of person you spoke to, and content of the communication. Use this information against them any time possible.
Phew! I'm exhausted just typing this. What a crock. Stay strong! I have been in your position and given up, which is just what the company wants. Best of luck to you.
posted by angab at 9:25 AM on November 7, 2010 [4 favorites]
Seconding what angab said. Depending on what their communication system is set up like, I'd also try to have these discussions by e-mail rather than telephone. That way, there's a paper trail of what they've actually said to you.
posted by J. Wilson at 9:59 AM on November 7, 2010
posted by J. Wilson at 9:59 AM on November 7, 2010
Definitely create a paper trail of everything at this point, and be sure to include a brief recap of the conversation you had (and the person with whom you spoke) that prompted your communication (e.g., "forms sent per request by customer service associate Meg Smith on Nov. 1, 2010"). I'd be leery of faxing anything at this point without backing it up by mail; additionally, all mail should be certified with a return receipt at this point. I got a nine-month phone/fax runaround over a hospital bill cleared up in a matter of days last year once I finally sent all parties certified letters CC'd to each other and the state attorney general.
posted by scody at 10:26 AM on November 7, 2010
posted by scody at 10:26 AM on November 7, 2010
Best answer: Do you have this health insurance through your employer? If so, go to HR with your problem. Your claim is much more likely to be paid if someone with the ultimate power to fire the insurer gets involved.
posted by MarkAnd at 12:09 PM on November 7, 2010 [1 favorite]
posted by MarkAnd at 12:09 PM on November 7, 2010 [1 favorite]
When I worked for a congressperson we got calls complaining about these kinds of things and someone in our office would actually call the insurance company and ask what was going on. It often helped. I don't know how helpful your representative is, but it can't hurt to call. Companies don't like getting complaints from congressional offices.
In any case, it's good to remind congresspeople how much private insurance companies can suck, because they seem to forget sometimes.
posted by walla at 9:38 PM on November 7, 2010
In any case, it's good to remind congresspeople how much private insurance companies can suck, because they seem to forget sometimes.
posted by walla at 9:38 PM on November 7, 2010
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posted by SpacemanStix at 8:28 AM on November 7, 2010