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Dispute with Insurance
Jun 19, 2012

My Group medical insurance has a $2000 deductible for both medical and prescription expenses. I satisfied the deductible when I filled my first 4 prescriptions on 1/16 and I have been paying the co-pay since.(I saved receipts) Until now. The insurer says they "disallowed" some of my expenses but can't tell me why and I now owe $600 for my Isentress for this month. Despite several calls to the insurer, I am always told that they are "working" on it. My managed health service was on the call with them and even they said I satisfied my deductible, but the medical insurance has wiped it off the records as if it never happened. I can pay the $600 this month, but what if they "wipe" that off the books too. Do I need a lawyer. What should I do.

Response from Mr. Chambers

Insurance companies do seem to operate in mysterious ways. They should not only explain why they are disallowing charges, they should be able to tell you what part of the contract allows them to do it and be willing to do so in writing.

If you haven't been keeping a log of your contacts with the insurance company, you should start now. Keep track of who you talk to and what they say.

Before resorting to an attorney, I suggest you contact the regulatory agency that oversees them. If it is individual coverage, it is probably your state's Department of Insurance. If, however, the insurance comes through an employer, it is regulated under the federal law, ERISA, and you should contact your regional US Department of Labor - Pension and Welfare Benefits office. You can find both agencies on line.

They should be able to help resolve the issue. At the very least, it will get the insurance company's attention and hopefully deal with you in a better manner than they have in the past.

Good luck, Jacques



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