I am so upset. I hate insurance.

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Regular Member

Date Joined Jan 2010
Total Posts : 492
   Posted 4/8/2010 8:35 AM (GMT -6)   
They didnt pay 60 percent of surgery like they were suppose to. They said my surgery was for a pre exsisting condition. When I talked to them before surgery  they said they will pay 60 percent . I asked them flat out if they would cover me they said they would pay 60 percent.so we now owe the hostipal 8,000 dollars for surgery. grrrrrrrrr.
im dxed with  herniated discs,fibromylagia , scolosis,ddd,athritis, spinal stenosis ,gerd,gastric ulcer,gastroparesis..gallbladder removal 3/23/10.
meds,ambien, prilosec otc,lortab ,reglan,flonase and  trazodone.

White Beard
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Date Joined Feb 2009
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   Posted 4/8/2010 9:10 AM (GMT -6)   

I am sorry that they are doing that to you, do you have the name of the person at the insurance company that you talked to? Didn't you have to get preapproval from them for the surgery? I definitely would be doing some checking into this! Didn't the hospital and doctor check this out before they did the surgery???

I do wish you Luck on this!

White Beard

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Date Joined Jan 2010
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   Posted 4/8/2010 9:26 AM (GMT -6)   
Hey Kimber,

I am sorry to hear that you are having more difficulties...I happened to be reading some back posts from late January and when some of the members were talking about this being a pre-existing condition...you said that you had long talks with your Dr. and he would make sure it was approved..

So just wanted to say that maybe you can go to him with helping you...I know that is why until 2014 and the health care law goes into effect for adults (Children are covered starting now no matter what), and pre-exisiting issues...I can't get covered by a regular insurance for some of my health problems...That is unfortunately one of the biggest clauses in an insurance contract..

What percentage are they paying for you? Unless you have a letter, in writing, from them saying that they will cover 100% of this surgery and it is pre-approved, then I hate to say you will be on the hook for the remaining costs...

I truly hope like White Beard said, that you can go back and look at all your paperwork, phone calls, email correspondence and get it straigtened out if it's an error on their part..

I am certainly sending you some hugs and prayer as you are going through a lot each day...

SB and "the pup who snores loudly" 
ACDF C5-C7, (no hardware), with autograft bone Nov. 2001
(reabsorption of bone 2 years later...still lost in body..expect to burp it out at anytime..haha")) 
ACDF with hardware, allograft bone Nov. 2005 
Anterior and Posterior CDF, allograft bone with BMP, removal of old hardware, use of titanium plates, rods, screws, & kitchen sink (lol) Dec 2006

Veteran Member

Date Joined Aug 2006
Total Posts : 9607
   Posted 4/8/2010 10:17 AM (GMT -6)   
Awe Kimber, sorry this happened to you and if you can try to send it in for appeal,
state that you where quoted 60% coverage by phone from their Insurance agency, maybe that
would help, but definitely try to appeal this...Good Luck to you...
* Asthma, Allergies, Osteoarthritis, Spinal Stenosis, Degenative Disc (Lower Lumbar S1-L3 and Cervical C5,C6, C8 and T1), Fibromyalgia, Gerd,
Enlarged Pituitary Gland, Sjogren's, Ocular Migraines, mild carpel tunnel, ect.... "Would be nice if we could use the edit button in real life"...


Regular Member

Date Joined Jan 2010
Total Posts : 492
   Posted 4/8/2010 10:23 AM (GMT -6)   
Chart,thanks that what we are in process of doing. I dont understand how they consider it pre exsisting cause drs didnt actually know for sure it was my gb til I had the hida scan was done and I had insurance when i had it done. the insurance payed for the hida scan but not my surgery. I am so frustrated.We knew we would have to pay 40 percent of surgery costs and we were going to do that . I am just upset if they deny our appeal we will have to end up paying for 100 percent and there is no way we can come up with 9,000 dollars.
im dxed with  herniated discs,fibromylagia , scolosis,ddd,athritis, spinal stenosis ,gerd,gastric ulcer,gastroparesis..gallbladder removal 3/23/10.
meds,ambien, prilosec otc,lortab ,reglan,flonase and  trazodone.

Mrs. Dani
Veteran Member

Date Joined Jun 2009
Total Posts : 2787
   Posted 4/8/2010 10:45 AM (GMT -6)   
   Dear Kimber,
     I am so sorry they are doing this to you. I hope your appeal goes well. I have been..reminded latley from my own insurance carrier just how cruel and impartial they can be. You are in our hearts and prayers here! Try to focus on getting better and healing. Our hearts are with you



Two roads diverged in a yellow wood,
And sorry I could not travel both
And be one traveler, long I stood



Veteran Member

Date Joined Feb 2009
Total Posts : 999
   Posted 4/8/2010 10:51 AM (GMT -6)   
Kimber, You have already received some good advise in regards to steps to take. I would concentrate on talking to your dr as it depends at time what code he uses when he bills the ins company. As was stated, you can also appeal with the ins. The other step that is a possibility is talking with the hospital and explain that you now are in the financial bind and see if they have some kind of assistance program where part of it could be paid for. It is has hard to remaain calm but remember the insurance company is not connected to God, they just think they are.

solar powered
Veteran Member

Date Joined Nov 2007
Total Posts : 538
   Posted 4/8/2010 10:56 AM (GMT -6)   
Kimber, I am so sorry that you are having this problem. That totally sucks and is so unfair. I would definitely keep on the insurance company about this. I would also consider calling the hospital where you had the surgery done and talking to the patient advocate there. They may have some ideas for you as to how to deal with the insurance company or will be able to set-up a payment plan or financial aid if the insurance comp still refuses to pay what they promised you. They also may be able to put a hold on your account to give you time to get things figured out. Try not to panic but call everyone you can think of who could help get this straightened out. I wish you the very best of luck with this problem. Lisa
If I can laugh at it, I can live with it.

Veteran Member

Date Joined Mar 2008
Total Posts : 2976
   Posted 4/8/2010 11:26 AM (GMT -6)   

Can you file an appeal against their decision? I know a lot about insurance appeal processes because of my recent experience. Ask your doctor to write your insurance company a letter.


Veteran Member

Date Joined Jan 2010
Total Posts : 1097
   Posted 4/8/2010 11:29 AM (GMT -6)   
Awww, Kimber....this is the last thing you need to be dealing with as you try to heal. I am so sorry it's happened, and I hope that you are able to get it resolved quickly, so you don't have to stress about it.

Big hugs,
Conditions: Fibromyalgia, Chronic Pelvic Pain, FAI, Reynauds, IBS, Interstitial Cystitis, Surgical Adhesions, Ophthalmic Migraines, Severe Hot Flashes (Surgical Menopause and drug related), plus physically unable to vomit due to Nissen, and I have extremely tiny veins...a joy for blood work or IV's)
Surgeries: Appendix, Uterus, Nissen Fundoplication for GERD, Left Ovary, Gallbladder, Right Ovary, TVT
Medications: Oxycontin, Tramacet, Cymbalta, Flexeril, Clonidine plus Vitamin D and Multi-Vitamin daily

Regular Member

Date Joined Jun 2009
Total Posts : 256
   Posted 4/8/2010 12:25 PM (GMT -6)   
I'm sorry for what you are going through Kimberly... I too and having a similar issue where insurance pre-approved a Prolotherapy treatment from me... I went to a surgical center where I was being put to sleep as I was getting 24 injections in the back of my neck each time... I was on the table with an IV in my arm for my fourth treatment and the Dr. came in a said as of that morning my insurance company refused to pay on any of the past three treatments.... I had an IV in on the table in the surgical center.....

After the Dr's office disputed it they paid on the first procedure (I had three total) I did not end up getting the fourth treatment...

Insurance refuses to pay on the second and third treatment and now my Dr's office is going after me for payments.... telling me I am responsible for knowing what I can or can't get....I was under the assumption that the Dr's office handled all of the red tape...... I am getting the feeling he doesn't want to treat me now until he gets paid and am now uncomfortable going there....

All the treatment were approved before hand so I just don't understand why they can now reneg... and I am left holding the bag?????

It's total BS... and not fair what these companies are allowed to get away with..... sorry for what you are going through... you are not alone... write to your Congressman, write to anyone who listens... go to the news station or paper...find anyone who will listen....
Slight reversal of the normal cervical curvature. Ther eis a 2mm antherolisthesis of C3 with respect to C4, a 2mm retrolisthesis of C5 with respect to C6 and a 2mm retrolisthesis of C6 with respect to C7
Degenerative changes present at multiple levels as follows:
C2-C3 osteophytes medial to the right intervertebral foramen and involving the right uncovertebral joint with minimal to moderate foraminal narrowing.
C3-C4 herniation fo the disc medial to the right intervertebral foramen and encroaching uponthe medial aspect fo teh foramen measuring approx. 2.5mm in the AP diameter. There is marked compression of the right nerve root sleeve. There are osteophytes involving the right uncoverterbral joint with moderate to foraminal stenosis. There is minimal anterolisthesis of C3 with respect to C4
C4-C5 herniation of the disc in the midline measuring approx. 2.5mm in the AP diameter woth minimal flattening to the ventral aspect of the cord. There are osteophytes involving the right uncovertebral joint with moderate foraminal narrowing
C5-C6 posterocentral herniation of the disc measuring approx. 3mm in the AP diameter with flattening of the ventral aspect of the cord. There are osteophytes involving the right uncovertebral joint woth moderate foraminal narrowing. There is minimal retrolistesis of C5 with respect to C6
C6-C7 minimal retrolisthesis of C6 with respect to C7. There is minimal diffuse bulging fo the annulus measuring approx. 2mm in the AP diameter. There are osteophytes involving the uncovertebral joint bilaterally with minimal bilateral foraminal narrowing.

Been off all medications for almost one month... couldn't deal with the side effects.... now only using 5% Lidocaine patches

Veteran Member

Date Joined Jul 2009
Total Posts : 2042
   Posted 4/8/2010 1:13 PM (GMT -6)   
IMHO, most likely what happened is some basement dwelling bean counter at the insurance company noted how quickly you had the tests and surgery after you became insured and said "Hey, this couldn't have just happened. Must be a preexisting condition." They might be able to justify this too if you went to see any doctor before getting insurance for the symptoms you ended up having surgery for.

By all means appeal the insurance company's decision, but also look into having the outstanding balance written off at the hospital. I don't know what your income is (none of my business) but you might be surprised by how much income a person can have and still qualify for "charity" care at the hospital.
2 confirmed herniated lumbar discs. Spinal Arthritis. Spinal Stenosis, diabetic peripheral nueropathy.

Veteran Member

Date Joined Nov 2007
Total Posts : 6795
   Posted 4/8/2010 1:35 PM (GMT -6)   
I'm sad this has happened, but I have to say I'm not surprised. I remember suggesting to you that you likely could have a problem since you were getting new insurance, and had been treated for the condition before this new insurance went into effect. You were being treated for the symptoms, and likely the doctor had some diagnosis involving your gall bladder in your records even before the confirming scan. The scan may actually have served to confirm that this was a pre-existing condition because it was pieced together with previous reports from your doctor.

I'm no defender of health insurance companies, that's for sure, but the devil is in the details with them. And all of us, whether we like it or not, are ultimately responsible for paying our costs if our insurance doesn't pay. It'll be in the fine print at your doctor's office, the hospital, and the insurance contracts. Although it seems doctors are responsible for this, in reality it's all done as a service as doctors know most patients wouldn't follow through on the process of pre-certification and submitting claim forms, and thus the doctor or hospital would end up never getting paid, so they take it on as an extra service. I can say this because I've been on both sides of the fence, and the payments from insurance companies were, in essence, my pay check.

If you got something in writing that has a pre-certification number, especially if it's after the scan, you may have a leg to stand on in an appeal. Also you do need to see what your doctor's office did re: pre-certification, and if they got the approval after you had the test. I'm saying after the test because the test confirmed the diagnosis, but the preliminary diagnosis was made before you got this new insurance. If they pre-approved it after the test results were in, then the insurance co. should have had information from your doctor's records and been able to decide it was a pre-existing condition, and deny the approval. Unfortunately, while your doctor may have said he'd taken care of it, they usually have a person (or an entire staff) dedicated to doing these things, and he likely delegated it to them.

I do think the suggestion others have made about talking with the hospital, in addition to trying to appeal the insurance denial, about their charity program and what the income limits are for that is very worthwhile. Of our two major hospitals in my region, one will write off care if your income is below 200% of the federal poverty level, but the other (which has a religious affiliation) will write off care if your income is below 300%. So there can be quite a variation between hospitals.

The new health insurance reform is supposed to provide for a pool that adults with pre-existing conditions can buy into who can't otherwise get insurance until the rest of the changes go into effect in 2014. How expensive that coverage will be, though, I doubt has been determined. It will probably be some type of buy into one of the government programs, but that's better than nothing.

I know this isn't what you wanted to read, but I'm just trying to help you the best I can. And you know ultimately, you and your husband can only do what you can do. That's the attitude that keeps me somewhat sane these days regarding finances; I've had to let lots of things fall by the wayside, including what used to be an excellent credit rating. Sometimes survival takes precedence.

But at any rate it's going to be a long process, so I'd make a few phone calls to your doctor's office and the hospital and your insurance, but try to still focus on your healing. I know that's easier said than done.

Hope this helps a bit.


Forum Moderator

Date Joined Feb 2003
Total Posts : 13370
   Posted 4/9/2010 12:31 AM (GMT -6)   
Kimber, I think I was one too that raised the issue with you about pre-existing conditions with new insurance policies. Nearly all ins companies have pre-existing condition clauses, mine does. You said your dr said it was your gallbladder before you had the HIDA Scan, the HIDA SCANS show if a gallbladder is functionly properly or not. All my test were normal except the HIDA Scan. not surprised at all by them doing this. I am so sorry. I know with my ins company even if they pre-cert me for something it clearly states it is not a guarantee of payment, it sucks. Yes, I have been hung out to dry even with pre-cert which does not mean beans. All you can do is appeal and keep after them. Good luck.

crohns disease dx 2002 & small bowel resection, still looking for remission whatever that is, chronic pain 22 yrs, added ulcerative colitis 6-05 to the mix, high blood pressure 28 yrs, aortic heart valve insuffiency, depression, osteoarthritis, osteoporosis lumbar spine, scoliosis lumbar spine, peripheral neuropathy hands & feet, COPD & on oxygen therapy, lupus & psoriasis and psoratic arthritis. Several other health issues just not enough room to list it all. Too many surgeries to list and too many medications to list. Currently on 17 different daily medications. Intrathecal pain pump implanted June 05.

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