Apologies, but this is a long one. For context, I have PPO insurance. In May, I fractured my left ankle. An ambulance transported me to a terrible Brooklyn hospital that did not set my ankle properly and advised me to return in 10 days for surgery once swelling was down. Since I was in terrible pain, my husband made an appointment with his orthopedic surgeon (who is a provider under my insurance plan) the day after my fracture, and the surgeon said that the bone was trying to break through my skin, which I was beginning to see. He said I had to have emergency surgery that night instead of waiting ten days. I was sent to the emergency room of a Manhattan hospital to immediately have my ankle set into place, since it never was, and get ready for surgery. The hospital pre-authorized my surgery and even noted that the insurance was so good that it covered two nights stay. And in fact the insurance coverage is supposed to be fantastic - it’s the reason why my husband and his coworkers worked for this company (my husband has since left) because women would only pay $200 out of pocket for delivering babies. It’s supposed to be that amazing.
About two months after my surgery, I received a bunch of letters asking to call my insurance company about these claims. I called, and my insurance couldn’t explain why the letters were sent and told me everything looked fine. About three weeks ago, I received a $50k bill from a debt collector on behalf of the Manhattan hospital. This is how I found out my claim was denied. In fact, I found out another hospital claim for $50k and my orthopedic surgeon’s claim for $60k were also denied when I looked into it. Basically $160k total…denied.
When I called the insurance company, they couldn’t give a reason other than maybe possibly needing more info, such as verifying that I only have one insurance plan. As for my surgeon’s claim being denied, they thought it was a tax ID issue, but I coordinated with his office that it’s the correct one and he appears in network in insurance system. He’s also supposed to be covered especially since it was an emergency surgery. I was told they would look into this more since they verified my coverage and I could expect to receive a decision in 7-10 days. I just received a letter saying that they determined the claim was originally processed correctly according to the terms of my health benefit plan - no other explanation.
I’m curious if anyone has gone through something similar? I feel like they are trying to screw me and I genuinely want to go scorch earth. If this means retaining a healthcare lawyer, so be it. On principle, I can’t possibly let this company take advantage of me knowing full well they were supposed to cover every cent of this emergency.
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