Claiming health insurance

[kethu]

Dear Sir or Madam,
My parents took health insurance from a leading
insurance company for three months to visit Europe.My
dad is a diabetic patient and due to long touristic
walk he got blisters on his foot.We approached the
hospital for treatment of blisters and then we found
out that his blood sugar was above normal and the
doctor suggested immediate hospitalization for the
treatment of his diabetes.The hospital expenses came
upto 2000 dollars.The insurance company denied to pay
this amount showing the following clause in the
insurance policy as the reason''Acute decompensation
of diabetes *with the* (words between * added by the
insurance company)begining of ulceration&blisters
which has arised due to complications of diabetes.This
entire Policy does not provide benefits for any loss
resulting in whole or in part from, or expenses
incurred, directly or indirectly in respect of ''any
Pre-existing Condition.''The doctor's report
says,''The blisters are due to extensive
walking.Besides that, having diabetes made it
necessary to take special care of these wounds to
avoid worsening like ulceration.''We believe that
treatment of diabetes was compulsory for the treatment
of the wounds and the insurance must pay because it is
impossible to treat these wounds with high blood
sugar.Even though we pointed out these the insurance
company denied to reimburse the hospital expenses
repeatedly showing the clause in the insurance policy
as the reason. Do we have a strong case here to fight
back with the insurance company to get our money back?
If so , how can we proceed legally to file a case ?
Were there any similar situations which were solved
legally adn what was the result?
Thanking you in advance,
Sincerely
Sri

 

[NYClex]

No, I think you have a very weak case.

1) The blisters: You might have a case here, the insurance would have to show, that they in fact were caused by the diabetes. I am not a medical expert, but I have heard that diabetes can cause or aggravate this kind of affliction. So even in this point the insurance co. might have a good chance of prevailing.

I assume that the cost of the treatment for the blisters is the smallest part of the total bill.

2) Hospitalization and treatment of the acute blood pressure situation caused by underlying diabetes

Here the main costs will have occurred. If the company excluded preexisting conditions, of which diabetes is a classic example, generally and explicitly in the contract you will not win.

$ 2000 total costs also might be dwarfed by the costs necessary to fight this: legal costs, medical expert costs.

May be the bill is itemized and you can get the insurance company to compromise and pay at least the part for the treatment of the blisters.

But don't take my word alone. I am not an expert on health insurance conflicts.

 

[cbg]

"I am not an expert on health insurance conflicts"

Well, as it happens, I am. And I agree that this is a very weak case.

If pre-existing conditions are excluded, then pre-existing conditions are excluded. Period.

You MIGHT be able to argue the blisters as being unconnected with the diabetes. However, the policy does not read, "We don't pay for pre-exisiting conditions unless treatment is mandatory" - it says, "We don't pay for pre-existing conditions". The law is not going to force the insurance company to pay for something that is clearly excluded. If it was necessary to have coverage for the diabetes, then you needed to purchase a policy that does not have a pre-ex clause. They do exist.

At most, you might get treatment for the blisters paid for. That's all.