Insurance claim denied - any options besides a lawyer?
December 16, 2017 9:43 AM   Subscribe

AFLAC has denied a claim on my cancer insurance. I appealed and just got another denial letter. It's $300, so not enough to be worth hiring a lawyer over, but I'd like to know if I have any other options.

This is not a lot of money and in the great scheme of things isn't terrible, but it seems so unfair to me that I'm just angry. Maybe the answer is going to be that I need to just accept it, but I thought I'd see if MeFites have any other ideas.

So I have AFLAC cancer insurance. It works as extra money beyond what my health insurance pays, so it's not like I need it for treatment. The policy says that it pays $300 for each instance of chemotherapy, but it will not pay more than $300 for any given day.

My chemotherapy consisted of both pills and weekly shots. The pills were taken for 21 days, followed by 7 days off. On one specific day, I received a shot and the pharmacist put the pills in a bottle. That date was on my receipt for the pills. Because those two things occurred on the same day, AFLAC will not pay for the pills - even though I took them for 21 days and only had shots on three of those days.

In my rebuttal letter I pointed out that the policy uses the word "receives chemotherapy" and that I received it for 21 days. They responded that the date of service is the date the prescription was filled. I cannot find that in my policy, and they did not quote my policy on that - only the part that uses the phrase "receives chemotherapy."

I did once call my state's insurance commission over a company that had sold my employer a policy that was in violation of federal law, which is when I found out that the insurance commission was there to protect the insurance companies (I was told that the employer could buy the not-in-violation-of-the-law policy if they wanted to). Fortunately, once I pointed out the law to my employer, they changed our policy. I am not totally opposed to trying something like that again - but if I did, would that fall under the jurisdiction of my state or the state AFLAC is in?

As I said, it's only $300 (though it's only $300 for them too), and it's not enough to be worth hiring a lawyer over, but this just seems really wrong to me and it pisses me off. Is there anything else I can do? You are not my lawyer, etc.

(I do understand that they can only verify the date on the receipt, but they also can see that it's 21 days worth of pills.)
posted by FencingGal to Law & Government (5 answers total) 1 user marked this as a favorite
Every state has an insurance appeals process. I have done this twice. If you lose in the appeal process, you can probably go to small claims court.

In one case I won through the appeal process, in the other I lost in the appeal process, went to small claims, and won there.
posted by littlewater at 9:52 AM on December 16, 2017 [1 favorite]

they did not quote my policy on that

Before seeking redress via other means, write back to them demanding that they do just exactly that (quote the section of the policy that justifies their refusal to pay) and that if they cannot do that but still refuse your claim you will certainly be settling this in small claims court.

In my experience, polite yet dogged persistence wears down most instances of mindless resistance fairly quickly. Just make it clear to whoever you're dealing with that making you go away would take so long as to cost them more in level 1 responder wages than they're saving by stonewalling you.
posted by flabdablet at 10:15 AM on December 16, 2017 [4 favorites]

Could you post the exact language from your policy? Googling around just now, I found an Aflac cancer benefit schedule that says: "Aflac will pay the charges incurred up to $300 per day when any covered person receives one or more of the following cancer treatments...." If your policy reads like that, then the benefits are being administered correctly, since the prescription fill date is when the charges are incurred. (And from a health insurance actuary perspective, fill date has to equal date of service for drug claims, because there's not really a workable alternative, as the company doesn't know when or if you took the drugs.)

That being said, flabdablet's right about being persistent, as they might approve the claims anyways. Appeals to the insurance commissioner would be the next step after exhausting internal appeals. You could also try social media, as denying benefits because you didn't fill your prescription on a different day from getting chemo shots is a pretty shitty PR look for them.
posted by bassooner at 11:47 AM on December 16, 2017 [2 favorites]

would that fall under the jurisdiction of my state or the state AFLAC is in?

State of issue of your policy, not the state Aflac is in.
posted by frobozz at 12:37 PM on December 16, 2017

Seconding submitting the claim to your state's office for claims settlements.
posted by forkisbetter at 12:52 PM on December 16, 2017

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