Not Covered by Insurance

Well I knew it was too good to be true. I received a call from my surgeon's office inquiring about a bill in the amount of $4000.00. I was pretty taken by such a request. The office person stated to me that the insurance company paid the claim to me in Dec 04. I immediately called to insurance company who claims to have paid the claim to me. Of course I informed them that they are mistaken and that I did not receive a $4000.00 check from anybody let alone the Empire Plan. Well in the midst of my investigation I found out that my surgeon was an out of network provider and that I would be financially responsible for the services rendered. Now my question is, why did my insurance company or my surgeon's office prior to providing service not inform me? Is that not what the pre approval process is for? There are plenty of surgeons in my network even some in the same office that could have performed the service without the financial responsibility that I must now incur. I have submitted an appeal on the claim to the insurance company in hopes that they will pay the entire claim as communicated to me. This has definitely skewed my perception of the Center for Obesity Surgery (Orchard Surgical) at the Hospital of Saint Raphael's. I definitely will edit my glowing comments about that organization. I have been contacted by so many in the Greater New Haven area about that facility and practice and have until now given such great comments and resounding recommendations to use that facility and that practice in particular. I surly would not feel comfortable now giving such a spectacular recommendation. It is a shame that such great work by a wonderful surgeon is over shadowed by this type of event, but that is a part of the complete package and what you will be faced with when selecting a surgeon. I will keep you posted on this terribly disheartening situation.

Wow Frenchy.. to put it simply.. That really sucks! I can't believe that they can get away with that. I agree with you, that is why we go through the whole pre approval thing. Definately appeal it. I'm sorry that you are going through this whole ordeal after such a wonderful job you have been doing so far with the weight loss. It's just not right that they can get away with this. Definately keep us posted as what happens. I'll keep my fingers crossed that it all works out for you! ~Angel 222/166/120 BMI 32.4 Lap RNY 11/10/04

I'd be pretty steamed - There are two check points - one, the doctor's office would be informed in advance of your surgery if they were not covered & shouldn't have given approval without informing you in advance that you would have out of pocket expenses. The insurance comapany should have sent you a letter in advance of the surgery as well stating your approval and any limitations (mine wouldn't pay for any related complications). Appeal - and work your way up the chain of command at the insurance company & if that doesn't work see if an attorney will take the case on a contingency. Man - I hope this works out

I will keep you in my prayers. That is CRAZY!!! If it does not work then I say contact the Lawyer who helps with this. His name is on here somewhere. Keep us posted!!! HUGGGS Brenda

Frenchy, I'm so sorry that you're having to deal with this. I would think that there has to be some way to appeal this. The suggestion to get a lawyer sounds like a good one to me. There must be something that can be done considering you were cleared through the insurance and the doctor's office before the surgery took place. I'll keep you in my thoughts. Please keep us informed of how you're doing. Don't let this deter you from your goal to getting healthy. It's just a small bump (well, ok, a BIG bump!) in the road toward your ultimate goal. Keep your chin up! Deb

I would fight this all the way to court. I don't even know that you would need an attorney. I have never been to a doctor that did not inform me right away that they didn't take my insurance and demand payment up front. Matter of fact have you paid anything to the doctors office like a copay? Did they take and make a copy of your insurance card? Not to mention that most insurance companys when you go out of plan cover a portion of the service. For instance my covers 80% if I go to a doctor out of my plan. Just some thoughts. Good luck and keep us informed. Teresa

Hi Frenchy I really feel for you, these insurance companies are HORRIBLE!! When you received your approval letter for surgery were they specific? My letter stated how much would be paid in network nd how much would be paid outof netword. I hasd to pay $3,500.00 going out of network and my insurance paid the other 80%. Best of luck to you and dont give up with them!! Susan 11/24/04 376/292/180

Do you have a copy of your pre-approval letter?