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Case Study: Appealing Insurance Claims Denied on the Grounds of a Preexisting Condition
An Insurance Company
denied a hospital's claim based on policy language excluding coverage for
pre-existing conditions. Upon request, the patient provided a copy of his
policy and it was determined that pre-existing condition was defined as
"any condition treated prior to the effective date of coverage." Appeal
Solutions' first step on any pre-existing denial is to verify the exact
wording of the pre-existing clause.
Careful review of the
patient medical records prior to hospitalization revealed that the patient
was seen by a physician just days before the effective date of coverage.
This, of course, was an immediate red flag to the insurance examiner. The
physician records were obtained with the permission of the patient. The
records indicated that the initial physician who saw this patient was
unable to reach a conclusive diagnosis and referred the patient to a
specialist. The insurance coverage became effective after this initial
consultation but before a correct diagnosis was made by a specialist.
Legal research for a
similar case revealed a decision favorable to the provider's appeal. In
Scarborough v. Aetna Life Insurance Company, 572 S.W. 2d 282, the
Supreme Court of Texas ruled that medical care and treatment can
encompass a preliminary examination. However, for the preexisting
exclusion to apply, it is necessary that the insured received a medical
service for a known condition. In this situation, I successfully argued
that this patient's treatment prior to the policy effective date was for
an unknown condition. Therefore, the treatment, if any, rendered prior
to the policy effective date was for a different condition and did not
bring it under the preexisting definition as defined by the policy.
The Insurance Company
released benefits within 10 days of reviewing appeal letter citing this
application for Your Medical Facility:
The condition this patient suffered was parathrodism, often difficult to
diagnose. However, with many other conditions, such as athereosclorosis,
asthma and mental disorders, the early diagnosis is also often difficult
to make and subject to change. Each patient may progress through many
stages of these conditions. Cardic patients may initially be diagnosed
with heart palpatations or chest and arm pain in early stages of the
disease. Angina is often another precursor to atherosclerosis. The point
of the Scarborough case is that the treatment prior to the effective
date must be for a known condition and the same condition which is
currently being denied. In any pre-existing denial, we carefully review
the medical records to see if the diagnoses are the exact same before
and after the effective date. If not, the provider has an excellent
AppealLettersOnline.com can assist providers implement an effective denial management program.
AppealLettersOnline.com is an interactive resource provided to level the playing field between Insurance Companies and Medical Providers. You
will find appeal letters, case studies, articles, other resources and the latest intelligence necessary to help healthcare providers make
vital decisions and take strategic actions to address payer denial issues.
AppealLettersOnline.com will help health care
providers actively develop the processes, analytical tracking information, educational programs and procedures needed for
implementing an effective denial management program.
Some of the topics covered at AppealLettersOnline.com include addressing payment reductions such as usual and
customary and out-of-network care reductions, lack of timely filing denials, pre-existing conditions and medical necessity
appeals and improving verification of benefits procedures. Treatment exclusions, maximum benefits denials and
subrogation/coordination denials are also discussed. Tips are also provided on appealing for interest and penalty payment on
late payments and appealing a request for a refund of previously paid claims.
AppealLettersOnline.com discusses all types
of claims including Managed Care, Indemnity, Government, Self-Funded, ERISA
claim issues and managed care contractual payment discrepancies.
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