Health Insurance Carriers Declining People and Not Saying Why?

riskybiz · 01-12-2009, 03:11 PM

Are health insurance carriers obligated legally to inform a client why they are declining an application specifically?

I have a client who was declined because of an abnormal pap smear. We submitted information to underwriting from her Dr. stating that she has not had a bad pap smear and Coventry one is still saying that they are declining her due to a bad pap smear.

The only deduction I can make is that the carrier does not want her for some other reason for which they are not telling us.

healthagent · 01-12-2009, 03:34 PM

The carrier must tell the client the reason for the decline - but just the client - not the agent.

riskybiz · 01-12-2009, 03:40 PM

Originally Posted by healthagent

The carrier must tell the client the reason for the decline - but just the client - not the agent.

Yes I should have been more specific. The company is telling the client via a letter that she is being declined for abnormal pap smears. Her Dr. submitted info saying that she has not had abnormal pap smears.

So what options do they have? Go to the department of insurance?

healthagent · 01-12-2009, 05:31 PM

Your client can file an appeal and remit any records showing that there was no abnormal pap.

moonlightandmargaritas · 01-12-2009, 05:36 PM

Originally Posted by riskybiz

The company is telling the client via a letter that she is being declined for abnormal pap smears. Her Dr. submitted info saying that she has not had abnormal pap smears.

Sound like there may be a difference of opinion as to what constitutes an "abnormal" pap smear.

healthagent · 01-12-2009, 05:40 PM

Out of my experience? 99% chance the carrier is right - 1% chance the client is right. When it's all exposed that's when you hear...."Oh...THAT pap test, you see the reason for those results were..."

moonlightandmargaritas · 01-12-2009, 05:46 PM

Originally Posted by healthagent

Out of my experience? 99% chance the carrier is right - 1% chance the client is right. When it's all exposed that's when you hear...."Oh...THAT pap test, you see the reason for those results were..."

Exactly.

I mean really, what would be the interest of Coventry (or any other carrier) to decline someone without a problem? They're pickin' on 'em?

healthagent · 01-12-2009, 05:50 PM

I used to love that stuff:

Declined do to stress test:

Client: My results were 100% normal - nothing wrong!

Me with the carrier: Sorry but he is declined due to the results of his stress test but that's all the information we can give

Me to client: You have your records? Can you fax 'em?

Client: sure - give me your fax number

Me to client after reading test results: Says here you have an undiagnosed irregular heartbeat.

Client: Oh that? That doesn't bother me. Yeah, they wanted to put me on this med but I ain't going on no meds since I'm fine.

riskybiz · 01-12-2009, 08:24 PM

Originally Posted by healthagent

Out of my experience? 99% chance the carrier is right - 1% chance the client is right. When it's all exposed that's when you hear...."Oh...THAT pap test, you see the reason for those results were..."

Normally I would agree with you, however the Doctor sent the supplemental records to me, including her pap smear results from 2000-2008 and additional colposcopy report ( more inclusive pap smear type test) which alll came back normal.

The original decline stated that they were declined due to abnormal pap smear results, we appealed ,provided the additional information and they sent the same letter again.

I know they ordered medical records and it was the same Dr. that sent the additional information stating there were no bad paps.

So what do you do in this scenario, let her have a decline on her record for something that isn't true?

moonlightandmargaritas · 01-12-2009, 08:31 PM

Originally Posted by riskybiz

and additional colposcopy report ( more inclusive pap smear type test) which alll came back normal.

Not trying to be argumentative, trying to understand the situation, but here's my question:

Why would she need a "more inclusive pap smear-type test" if her original was "normal" and unremarkable?

riskybiz · 01-12-2009, 10:42 PM

Originally Posted by moonlightandmargaritas

Not trying to be argumentative, trying to understand the situation, but here's my question:

Why would she need a "more inclusive pap smear-type test" if her original was "normal" and unremarkable?

She was asked to participate in a clinical research study for a more inclusive test. The test was not due to any medical problems and she was compensated for her time. This could be the reason for the decline, I don't know, just tell her why.

They sent the exact same letter for the declination after the appeal and submission od additonal information. If anything go into more detail and give us a clue.

agent4sail · 01-12-2009, 11:24 PM

Errors frequently occur do to erroneous information contained in MIB records. Your client may need to order her MIB and see what information is being reported to the carrier. I was declined for a health insurance policy because of my MIB. When I checked the records I found that I had many, many issues I did not know I had. The report listed 3 surgeries I wasn't aware of. After carefully checking where this info originated, I found another lady with my name, same city, same age, same physician, her records had been combined with mine. It was being furnished by MIB as my medical records. It took many letters and the threat of legal action before it was corrected. If I had not been aware of the MIB reporting, I may never have known how to get my medical records corrected.

somarco · 01-13-2009, 07:49 AM

She was asked to participate in a clinical research study for a more inclusive test. The test was not due to any medical problems and she was compensated for her time. This could be the reason for the decline

Aha!

Good chance that trial, or some information from it, showed up at MIB.

If so, the carrier picked that up and declined. It can happen with other carriers as well.

If she took meds as part of the trial, that will almost certainly be reported to Intelliscripts (or some similar organization).

Coventry is about as squirrelly as any carrier when it comes to underwriting. I refer to them and Jekyll & Hyde because you never know what you will get.

You need to make a case to the underwriter, either Coventry or the next carrier.

Make your case in a logical fashion.

She did not have an abnormal pap.

She opted to participate in a clinical study because . . .(insert explanation here).

The study results showed . . . (insert outcome here).

Not saying it will work but you have to at least try and be proactive, not reactive.

healthagent · 01-13-2009, 08:17 AM

If indeed she is healthy you have a good chance by submitting it for review with ALL of the information. I don't see where participating in a clinical study is a reason for decline.

That said, I'm gonna dial up my underwriter today. I have a bad feeling if she took any experimental drugs that could be game, set and match.

CPACINS · 01-13-2009, 09:53 AM

Originally Posted by riskybiz

She was asked to participate in a clinical research study for a more inclusive test. The test was not due to any medical problems and she was compensated for her time. This could be the reason for the decline, I don't know, just tell her why.

They sent the exact same letter for the declination after the appeal and submission od additonal information. If anything go into more detail and give us a clue.

She is being declined because of the colposcope. Usually the only reason for a colposcope is irregular pap. Coventry is seing that on her record and it's an auto-decline. You will need to get something stating from the Dr that she did this for a research trial and that nothing was wrong. It will need to be something different than just her records. Like a letter from where the trial took place and why and then file the appeal.

healthagent · 01-13-2009, 09:59 AM

Just off the phone with an underwriter; taking part in a study does not trigger a decline. However, I was correct about any meds. You did not state whether or not she took any experimental medication but if she did that could be a reason for the decline - subject to UW review of course.

riskybiz · 01-13-2009, 11:22 AM

Thank you very much for all of your input, it has been extremely helpful!

I should not have to go out and seek out all of this information for something like this, the carrier could and should be a little more helpful in ascertaining the reason why someone is declined. I have requested more specific info from the underwriter and hopefully will hear something in the" next couple of weeks!" talk about customer service.

We are going to try another carrier.

healthagent · 01-13-2009, 02:25 PM

Personally, going to another carrier without knowing the specific reason for the decline is like shooting in the dark. You need to know the reason before you go off to carrier B.

somarco · 01-13-2009, 09:43 PM

I should not have to go out and seek out all of this information for something like this,

Nope, that's what you get paid for . . .

riskybiz · 01-13-2009, 11:45 PM

Originally Posted by somarco

Nope, that's what you get paid for . . .

I should not have to go on a message board to try to find out why my client was declined. The insurance company should be able to tell my client specificlly why they are being declined.
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Originally Posted by healthagent

Personally, going to another carrier without knowing the specific reason for the decline is like shooting in the dark. You need to know the reason before you go off to carrier B.

This has been going on for 2 months. Her Cobra coverage is about to expire. What else can I do, keep appealing? Short term could be tricky, because technically she has been declined.