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Claiming health insurance

Discussion in 'Health Insurance, HMO, HIPAA & Disability' started by kethu, Jul 2, 2004.

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  1. kethu

    kethu Law Topic Starter New Member

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    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,
  2. NYClex

    NYClex New Member

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    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.
  3. cbg

    cbg Super Moderator

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    "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.

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