Question:
Have you ever had your insurance approve the surgery and then not pay

I received my approval letter back in September, had the surgery done and now three months later my insurance company is threatening not to pay, for pre existing. Why would they approve it and then turn around and not pay for it? That's kind of wrong.    — Tiffany C. (posted on December 26, 2003)

December 26, 2003
Not only is it wrong, I think it may be illegal. Just send in an appeal with a copy of the approval letter. I believe if you have an approval in writing they have to honor it. Your physician probably didn't refer to the approval when submitting your claim or else the approver who processed the claim did see the approval in your history. I would try calling the insurance, with the claim number and trying to resolve it over the phone first. 2nd send in the written appeal with a copy of the approval. If you don't get satifaction, the next step is to write to your state insurance commissioner and they will investigate. Don't get stressed, I used to work for a major insurance, this happens all the time and it will be resolved.
   — Carolyn B.

December 26, 2003
I worked medical review for 6 years for a huge, well known company. (won't mention here) If a letter of approval goes out, they have to honor it. Call and speak with the highest supervisor,(remember everyone reports to someone, if no satisfaction, go higher) Say you have the approval letter and are going to be calling the insurance commission and perhaps the local TV channel unless this is resolved immediately. You sound really nice, but you have to be tough and mean it. Good Luck!
   — ZZ S.

January 5, 2004
I also worked for insurance companies for 15 years. Normally, in the letter advising the surgery is covered most insurance companies will also include a tag line "subject to pre-existing and based on the plan benefits". If they mentioned anything like that in the letter, then no, they did nothing wrong. If you were treated (either by seeing a doctor or taking medication) for the treatment of obesity, prior to your insurance being in effect, then it is a pre-exising condition. If there was nothing mentioned in the letter, your probably still not going to win the fight with them only because they gave you a certificate of benefits when you bought the insurance and the certificate of benefits defines what's not covered under your policy. Pre-existing is one of those things and it defines it in your certificate booklet.
   — Patty H.