Health Insurance Claim Issue

stevie123c

I'm little livid at the moment so I think the best way to go through this is to give the facts and then ask for advice.

- Joined health insurance company in Nov '11
- Went to dentist in December with toothache, turned out to be gum infection. Recommended that molars may need to be removed to prevent recurrence
-See specialist in early '12 . Recommended removal of molars as well. Asks if I have insurance, when did I join them and when was the original recommendation given. Give him all the details and he says I'll be covered.
- Schedule date for surgery and contact insurance company to ensure I'll be covered. They say I will be but there is a price drop off of 255 to be paid out of my own pocket for the hospital I've chosen , this isn't a problem.
- Two weeks before surgery I call again just to ensure I'm convered. Again told I would be.
- Have surgery in early April
- Today on the 18th of September I receive an invoice from the consultant/surgeon and a letter from insurance company informing me due to the information received with my claim the symptoms of my condition (having teeth) were present before joining them and they won't be paying.

What's my next step ? Who can I contact for help ?
Do I have a case?

chris85

stevie123c wrote: »

I'm little livid at the moment so I think the best way to go through this is to give the facts and then ask for advice.

- Joined health insurance company in Nov '11
- Went to dentist in December with toothache, turned out to be gum infection. Recommended that molars may need to be removed to prevent recurrence
-See specialist in early '12 . Recommended removal of molars as well. Asks if I have insurance, when did I join them and when was the original recommendation given. Give him all the details and he says I'll be covered.
- Schedule date for surgery and contact insurance company to ensure I'll be covered. They say I will be but there is a price drop off of 255 to be paid out of my own pocket for the hospital I've chosen , this isn't a problem.
- Two weeks before surgery I call again just to ensure I'm convered. Again told I would be.
- Have surgery in early April
- Today on the 18th of September I receive an invoice from the consultant/surgeon and a letter from insurance company informing me due to the information received with my claim the symptoms of my condition (having teeth) were present before joining them and they won't be paying.

What's my next step ? Who can I contact for help ?
Do I have a case?

Was the condition present prior to you taking out the policy? Pre existing medical conditions are rarely covered.

stevie123c

chris85 wrote: »

Was the condition present prior to you taking out the policy? Pre existing medical conditions are rarely covered.

That's the thing , I didn't have any condition. Went to the dentist with a gum infection and was recommended I should have my molars removed.

chris85

stevie123c wrote: »

That's the thing , I didn't have any condition. Went to the dentist with a gum infection and was recommended I should have my molars removed.

Ok that still doesn't clarify it. If you have a history of gum issues they may have a case to say it was pre existing. Have you had any previous issue with your teeth? The timing of both letters seems like recent conversation between insurer and consultant where insurer may have been unhappy to cover it. Have you talked to consultant about it?

If unhappy you can make a formal complaint with the insurer. If unhappy with their response you can complain to ombudsman about it.

okiss

You should have rang your health insurance company to check if you were covered for this as not all health insurance policies cover dental work.
I would argue with the health insurance company over this.
You should be able to claim with a med 2 form to get 20% of the cost back.

dave98

Hi there, Firstly, my advice in future is instead of ringing the insurance company, email them your question and then its in black and white. The reason I say this, is I had an operation done in July for nearly €1500. Before the operation, I emailed the insurance company telling them exactly what was been done. They said I was covered. 2 weeks ago, like your story, I got a letter from both insurance company and hospital saying insurance company wasnt covering it.
I rang the insurance company, got speaking to a supervisor and she asked if I would forward on the email and bang, a week later I got a letter to say the hospital had now been paid.
Also, earlier on in the year, my friend had dental work done. Like you, they said he was covered. Then after it they said he wasnt. He accepted their decision and paid for the dental work. A few days later he told his mam the story and she rang the insurance company and argued the case and he got a refund...
Fight for it man, they will have a record of your queries before you had the work done!