Misdiagnoses leads to denial of claim for kidney dialysis
April 20, 2010 1:52 PM   Subscribe

What can be done when a health insurance claim is denied due to a mis-diagnosed condition being considered a preexisting condition?

My sister experienced mid stage kidney failure while she was pregnant. She gave birth over a year ago and her kidney function returned to normal, testing was inconclusive and the doctors diagnosed the issue as a complication of the pregnancy.

In the last week her kidneys have failed and she was to start dialysis this week. When she arrived at the hospital to have the tap installed for her dialysis the hospital refused do the procedure because her insurance company denied the claim based on the symptoms during the pregnancy.

She has now been diagnosed with PKD. (http://www.pkdcure.org/)

She has and individual plan in Illinois.
She has had no lapse in coverage.
posted by anonymous to Law & Government (16 answers total) 3 users marked this as a favorite
Even though she's insured, you might be able to find help through this office.
posted by availablelight at 2:02 PM on April 20, 2010

pre-existing condition typically refers to a condition that existed before you obtained insurance coverage. If she had never been diagnosed with kidney problems prior to obtaining coverage with this insurance company, it shouldn't be a problem. Did she change companies since pregnancy? And, if she did change, and it is a private carrier, they may be within their rights. The original diagnosis was correct, the finding of it being a complication of the pregnancy was the incorrect diagnosis...

This is a tricky one....
posted by HuronBob at 2:11 PM on April 20, 2010

This may fall under what is called a "never event" meaning the doctor misdiagnosed or missed the initial diagnosis or made a mistake in diagnosis. The insurance company is not going to claim responsibility nor pay for any kidney related issues that were related to this pregnancy due to doctor error. She has to take up any billing with the doctor/hospital and have him cover it.
posted by stormpooper at 2:16 PM on April 20, 2010

You could start a fight by contacting Lisa Madigan's office and sending some press releases out. She fought a good fight for a friend's father who had off labeling concerns, insurance denials, and sadly--death. It was too late for the blue office on Randolph Street to change their minds and help this guy.
posted by stormpooper at 2:20 PM on April 20, 2010

Please talk to a lawyer in Illinois who is familiar with the recent Illinois Insurance Fairness Act. It does not got into effect until July 1 as far as I can tell, but I am not a lawyer and you may have some options before then; under this law, as of July, you will be able to appeal medical claim denials to an external, independent reviewer after having exhausted the company's internal appeals procedure.
posted by enn at 2:23 PM on April 20, 2010 [1 favorite]

1. Pay no attention to what stormpooper said. The doctor who missed the diagnosis did not cause the disease.

2. She needs to get the policy language to see precisely how the exclusion is worded.

3. She needs an opinion from a doctor as to whether this was in fact pre-existing. (To tell the truth, I have never heard of pregnancy-related kidney failure not related to pre-eclampsia.)

4. As HuronBob says, if this is the same company that insured her when the pregnancy-related diagnosis was made, there should not be a problem.

5. Health insurers are notorious for claiming this exclusion on the flimsiest of evidence. Their expectation and experience is that a large percentage of their insureds will not push back. She needs to push back.
posted by yclipse at 2:35 PM on April 20, 2010

Never events: http://en.wikipedia.org/wiki/Never_events

Yclipse--Working in the industry which is the subject at hand, I do know what I'm talking about.
posted by stormpooper at 3:00 PM on April 20, 2010

Where on that list are you seeing anything that resembles "misdiagnosis" as a Never Event? Surgery on the wrong patient or body part, sure; care provided by someone impersonating a medical provider, sure; leaving a sponge or other item inside a patient accidentally, sure; insemination with the wrong semen, sure... but misdiagnosis doesn't seem to be anywhere there.

Nor should it be — the "Never Events" are things that should, by definition, never happen. Misdiagnosis is regrettable but in most cases isn't a black-and-white-no-shades-of-grey matter, unlike something like physical assault by a care provider or administering contaminated medication.
posted by Lexica at 3:19 PM on April 20, 2010

Wait, she has had the same insurance company the whole time?

Call Lisa Madigan. She da bomb for that kind of stuff.
posted by gjc at 5:23 PM on April 20, 2010 [1 favorite]

we don't know that she had the same insurance company... the op doesn't say that.
posted by HuronBob at 5:54 PM on April 20, 2010

Kidney failure and dialysis, kidney transplant, etc., is a field that is very heavily regulated vis-a vis MediCaid. She should talk with the dialysis social worker about this. She may be an excellent resource and help for her. (I don't just menan for the psychosocial stuff. I mean for the regulatory/insurance stuff.)

It is not my area of expertise, but I have had a number patients who happened to be on dialysis and the dialysis social workers were very knowledgable about insurance questions.
posted by SLC Mom at 6:12 PM on April 20, 2010

And my empathy to your sister for dealing with all of this--from a health standpoint and an insurance nightmare. I wish her good luck and good health.
posted by stormpooper at 6:34 PM on April 20, 2010

From the OP:
She had a group plan with Blue Cross/Blue Shield when she was pregnant and misdiagnosed. She is currently on an individual plan with another company. Her employer does not provide a group plan.
posted by jessamyn (staff) at 10:48 AM on April 21, 2010

SLC Mom's comment brings this point to mind: A person who suffers from end-stage renal disease is eligible for Medicare coverage at any age. I do not know the details, including how much of a waiting time there would be, but the hospital will know for sure.
posted by yclipse at 1:25 PM on April 21, 2010

Knowing the details, this will be hard to fight. The best course of action IS to get press, lots of hoopla while arguing with the insurance company. Insurance companies don't like bad press and they have caved numerous times because of it.

Again, I'm sorry she's going through all of this.
posted by stormpooper at 1:40 PM on April 21, 2010

I would suggest trying the Illinois Department of Insurance. My mom had an issue with her insurance company and they were a big help. Her problem was completely different than your sister's, but I think the department deals with all sorts of health insurance issues:

posted by parakeetdog at 1:52 PM on April 21, 2010

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