by mkusiak » Mon Dec 17, 2007 12:49 am
My father was paralyzed on Sept. 9th, 2007, after he suffered a accidental fall after his treestand gave out from beneath him. However, our insurance company has yet to pay anything since his date of injury, far over the typical 30 day time alloted. On November 9th, we were informed that as of November 7th, our insurance company had only authorized three more days, which would have been up the next day, November 10th. The reasons as to which were left unknown, to both us and to the facility he was receiving care from.
The only response we could get from our insurance company was that, ‘patients benefits are suspended due to claim investigation.' When we questioned them for advice or what they would like us to do, or where they would like us to admit him, we simply were left with a mere, ‘we're sorry ma'am.'
However we were aware the fact that our insurance company was battling the charges associated with my father going to that specific nursing home, as it was 'out-of-network'. Reason being, when we brought him back to his original hospital and admitted him into the rehab program in the closest proximity of our home address; therefore, complying with the insurance companies wishes by placing my father in a facility which would be ‘in network.'
We have adhered to everything that they had asked of us, though to date, our insurance company has yet to validate the fact that my fathers care will be covered by them. Ultimately, such actions, or lack there of, have implemented additional stresses on our own lives and financial stability, for a reason that is completely unjustifiable.
The problem with our insurance company needs to be resolved in a timely manner, now moreso than ever, as he is scheduled to be released from his rehab this Friday, Dec. 21st. However, our insurance company orginalled agreed to 8 weeks at Mayo Clinic- and he has only completed 4, as they had to divide his insurance into two phases, due to the restrictive nature of his braces. We do not want him to be released- because the chances of him being re-admitted after returning home would be rare. On the other hand, we do not was to re-admit him, come to find later that they in fact are not going to pay.
Is there any legal action we may take against them for not providing answers for such an extended amount of time?
The only response we could get from our insurance company was that, ‘patients benefits are suspended due to claim investigation.' When we questioned them for advice or what they would like us to do, or where they would like us to admit him, we simply were left with a mere, ‘we're sorry ma'am.'
However we were aware the fact that our insurance company was battling the charges associated with my father going to that specific nursing home, as it was 'out-of-network'. Reason being, when we brought him back to his original hospital and admitted him into the rehab program in the closest proximity of our home address; therefore, complying with the insurance companies wishes by placing my father in a facility which would be ‘in network.'
We have adhered to everything that they had asked of us, though to date, our insurance company has yet to validate the fact that my fathers care will be covered by them. Ultimately, such actions, or lack there of, have implemented additional stresses on our own lives and financial stability, for a reason that is completely unjustifiable.
The problem with our insurance company needs to be resolved in a timely manner, now moreso than ever, as he is scheduled to be released from his rehab this Friday, Dec. 21st. However, our insurance company orginalled agreed to 8 weeks at Mayo Clinic- and he has only completed 4, as they had to divide his insurance into two phases, due to the restrictive nature of his braces. We do not want him to be released- because the chances of him being re-admitted after returning home would be rare. On the other hand, we do not was to re-admit him, come to find later that they in fact are not going to pay.
Is there any legal action we may take against them for not providing answers for such an extended amount of time?
Posted: Mon Dec 17, 2007 10:38 am Post Subject:
Good morning mkusiak, and welcome to the community...I am so very sorry about your father's injury, I have horrible chills as my husband is an avid bow hunter and must have 20 stands in operation as we speak!
My father was paralyzed on Sept. 9th, 2007, after he suffered a accidental fall after his treestand gave out from beneath him.
Is there any legal action we may take against them for not providing answers for such an extended amount of time?
There are rules/laws that govern what an insurance company can do, and time lines associated with same. Unfortunately, in general terms, they can stay some of these time lines by stating in writing that they are investigating coverage,‘patients benefits are suspended due to claim investigation.'
But seems they have had ample time to clear this up...what is the nature of the investigation do you know? What type of health coverage is this? ie from him employer, private policy?You don't mention your state, but all have web sites with the information on whom to contact, get in contact immediately with your states Dept of Insurance. They should be able to assist you ....
Hopefully another member with health insurance experience will come along with additional suggestions (my experience is P&C)....Again so sorry please answer the questions re: type of insurance, and contact your state DOI, let us know what they have to say.....My thoughts and prayers for your Daddy and your family.
Posted: Mon Dec 17, 2007 07:37 pm Post Subject:
thank you so very much Lori- I really appreciate it. We are from Wisconsin and our insurance coverage is provided through my mom's employer. My dad was a dairy farmer, and therefore, had no personal policy- but rather, was covered under hers.
I too would suppose that they have had ample time to clear everything- however, this is not the case. We have no idea as to what they are investigating, but have a few ideas. The first of which, is that on Nov, 25th we received notification from my fathers admitting hospital, in which they stated that it has been 45 days and they have yet to receive payment from our insurance. Therefore, they asked that we contact our insurance in order to address any concerns.
We did- and my mom was asked a few (3) questions- the last of which was 'who's land was he on?' My mom informed them that he was on our own property. After which, they said thank you and that was everything they needed.
For this reason, we believed that they were attempting to determine if they could contact our homeowners insurance company- and make them semi-responsible for the bill. Later that day, my aunt (who works for a homeowners insurance company) came to visit- and after I explained the situation to her, she informed me that you are not responsible for yourself on your own land- only other people. Such is why we were hoping that the claim would be expedited- as we did not think they would continue to persue our homeowners insurance if they cannot be held responsible. But, no luck- as almost a month has passed and nothing has changed.
To add to the stresses of such a catastrophic injury- we still do not know what is going to be paid for. In addition, we need an answer as to our options- as he is going to be released this week...and we do not want to re-admit him into a better facility if they will not pay for it (no way can we foot a $2,500/day bill). At the same time, we do not want to compromise my fathers care by denying him any potiential recovery he could gain by an intense (and expensive) rehab program.
Again, thanks for your help and well wishes..and Happy Holidays-
(P.S. A great Christmas gift would be a safety harness)
Posted: Tue Dec 18, 2007 06:06 am Post Subject: all the best!
You don't mention your state, but all have web sites with the information on whom to contact, get in contact immediately with your states Dept of Insurance.
Absolutely! The state DOI is a truly helpful body who'd not only guide you but would also be proactive towards solving your problem. At the same time they are a good resource bank full of information associated with your insurance. So, its better that you don't wait too long!
Do keep in touch with us...n keep us informed from time to time about the proceedings at your end!
Carla Mendoz
Posted: Tue Dec 18, 2007 06:28 am Post Subject:
mkusiak, I'm not an adviser but I just wanted to say how sorry I am to hear about your dad's accident and all the stress the family's going through.
Here's the link to the state of Wisconsin's Department of Insurance page you need to file a complaint. All I could think of to do to help was pass that on. (I believe it's okay to post the link with it being a government site. Can someone please correct me if I'm wrong?)
http://oci.wi.gov/com_form.htm
I hope the insurance company get their act together so you don't have this hanging over you all for much longer. Blessings to you and your family. I'll be holding you in my thoughts and saying a wee prayer for a speedy resolution to it all.
Posted: Tue Dec 18, 2007 11:54 am Post Subject:
This question
'who's land was he on?'
was to ascertain if they could bring anyone else into play...either medpay or liablity..which in this case the answer was no, since he was on his own property...very common and i would expect this question.....and your aunt is correct you cannot be liable to yourself...did they ask about the manu.of the tree stand or was it home made? See even if they want to or can pull in another party...still they should be getting on with paying dad's bills and can always subrogate against another party should they be able to come up with one...Please contact the DOI of WI, and see what they have to say about this...Have you ask them point blank, ''what is the hold up'' and ''will you auth him going back into a rehab fac. once he's released?"..
Have you thought about contacting SS? Surely he would qualify for disability now, and perhaps would switch to medicaid, which (once all the paper work is done) would cover him in full? Please start with your DOI....and let us know what they have to say.....
What is your daddy's prognosis? How is he doing emotionally? I worry so much about men when something like this happens they generally don 't take 'being down' very well...And your poor mama? oh my.......honey, your family has been on my mind and heart since I read your post...this is very close to home for us...(potential for this type of injury)...
(P.S. A great Christmas gift would be a safety harness)
He has several...started using them of his chosing about 10 years ago (he's 50 now)...think age and mortality kicked in thankfully!thank you so very much Lori- I really appreciate it.
Like everyone else (i'm sure) that is reading or posting this thread, i wish i could offer you all more....let's start with the DOIps..yes lilacsigh this is allowed
..(I believe it's okay to post the link with it being a government site. Can someone please correct me if I'm wrong?)
Posted: Tue Jan 22, 2008 05:50 am Post Subject: sue or appeal?
I apologize for my lengthy delay in responding. I have been working with a contact at the company who sold the Destiny Health Insurance Policy to my mother's employer. Apparently, the reason in their delayed decision was due to the fact that they were waiting on additional documention from my father's admitting hospital. However, our wait continued- which I was informed (through my contact) that the reason for the hold up was now due to the fact that they were awaitin a toxicology report.
Then on January 8th, we recieved a letter that they had in fact denied payment to all claims associated with my fathers injury.
Reason being, I requested that a copy of the toxicology report made available to us. On January 17th, I was notified by fathers admitting hospital that there was no toxicology report ever conducted. as the severity of his injury did not allow them enough time to get the needed sample speciman to the lab.
Therefore, we are looking to take the lext step (legally). Shall we put in an appeal or hire an attorney?
Posted: Tue Jan 22, 2008 10:15 am Post Subject:
What does toxicology have to do with it? Health insurance generally has no exclusion regarding anything like this...If you're drunk and get hurt, then they still pay the bills, I don't understand this Megan...Are they saying if your daddy had some illegal substance there is no coverage? What is the EXACT basis for their denial?
I think a free consult with an attorney is warranted here...you may have a bad faith claim here..(those can get really high)...Most attorneys give a free consult, then a case like this would be on a contingency basis, meaning the attorney gets a percentage only if there is an award. Please set up an appointment, this all is simply making no sense to me at all...I've never heard of such a thing re: health plans...
Please let us know the reason for the denial, and also look into seeing an attorney right now!
How is your daddy doing? Is he home or still in a care facility, and will they let him stay with no coverage?
Posted: Sat Jan 26, 2008 05:06 am Post Subject:
Oops...I apologize for my spotty previous post. The whole situation has my head spinning...here is a better description of what has happend. Ugh.
As of today, January 25th, 2008, we have received documentation from Destiny Health regarding their denial to the claims derived from my father, Ronald F. K-----'s, injury which occurred on September 9th, 2007.
As the policy set by Destiny Health states, “Certificate of Coverage, Section 8: Exclusions: 31. Wrongful Acts. Illness or injury caused or contributed to by: a. commission, or attempted commission of a felony, crime or illegal act; b. participation in a riot, insurrection or civil disobedience; or c. being intoxicated by alcohol or under the influence of illegal narcotics or non-prescribed controlled substances. Intoxicated, or under the influence, means that condition as defined by law in the jurisdiction in which the illness or injury occurred. The absence of a formal police report and/or formal criminal charges will not alter this exclusion.”
Upon denial by Destiny Health, I requested that the toxicology report be released to me, for review. On January 18th, 2008, I was notified by Julia, from the Department of Medical Records in Saint Joseph's Hospital that such report, indeed, ceases to exist. Furthermore, she went on to explain that in order to conduct a Toxicology report, the specimen to be sampled must be submitted to the lab within two hours, which was not done in my father's case.
To begin with the bad, according to the results we have most recently received, our attention was elicited to the following pieces of information prevalent in the emergency room record performed by Dr. X at Saint Joseph's Hospital. The results from an alcohol evaluation performed on 09-09-07 at 22:15 confirmed a Value of 22 mg/dL, whereas the Normal range was between 0-9.
The emergency room note, which appears to have been composed by Dr. X, trauma surgeon, Dr. Y, chief resident, and/or Dr. Z states that, “History of Present Illness: This is a 47-year-old male who had been drinking and using some marijuana. He was up in a tree stand. He apparently fell asleep and fell out. He sat in the woods for about 4 hours where he was found. He was finally brought to the emergency department.”
However, the assumption that my father fell asleep and used marijuana (that day) is, in fact, incorrect. In actuality, the tree stand gave out from beneath him, which resulted in his fall. Therefore, the injury was not caused, nor contributed to by his use of alcohol or illegal substances. For this reason, we would like that an appeal be made in order to justify such false accusations, with the hopes that due to the fact that there was alcohol present in my father's system, it cannot be attributed as a cause nor correlation to my father's injury.
I hope that the latter makes sense. Do you still believe that an attorney would take on this case, especially on a continency basis?
Thanks so much for all your help! And my dad is doing okay...probably would be a lot better if we didn't have this whole issue. He was released from rehab right before Christmas...so it was nice because we could all be home for the holidays. Next saturday, he and I will be moving to Atlanta for him to undergo rehab there. However, the length of time we will be able to stay there is really uncertain now...as we, by no means, have the money to cover the medical bills and an additional rehab. Hopefully it will be okay...
Posted: Sat Jan 26, 2008 11:52 am Post Subject:
Megan welcome back! I've been wondering about your family...Hope you don't mind honey, but I edited your post and removed some names, don't know that it could ever hurt you or your daddy's case, but don't want to take any chances...hope you don't mind...
First I've never heard of this!
c. being intoxicated by alcohol or under the influence of illegal narcotics or non-prescribed controlled substances. Intoxicated, or under the influence, means that condition as defined by law in the jurisdiction in which the illness or injury occurred. The absence of a formal police report and/or formal criminal charges will not alter this exclusion.”
However, I'm certainly not a health ins policy expert...man I know they must allow this exclusion in my state as I've had too many friends/family that have injuries and illnesses caused by this...according to this any liver disease from alcohol etc would be excluded! Wow...RE: the pot in Dad's system...that one I think you could beat, doesn't pot stay in your system like thirty days or something?
The booze not so much...however you have a great point re: the stand, do you still have the stand? Who found him and could they testify to the stand collapsing etc? This (I think) is where the crux of his case will lie...Yes, I still think there may be an attorney that would take it. If you have evidence still in tact or by way of testimony that can back you all up....Most attorneys will charge nothing for the first consult, so no money out of pocket there....Won't hurt to try.
indeed, ceases to exist
What does that mean ceases to exist? Where is it?This of course is where you will attempt to 'hang your hat'
caused or contributed to by
Err go the tree stand evidence...Has the insurance company talked to whomever found him? Ask to see the tree stand? any investigation in an attempt 'to find coverage'?
Let us know about this, I think there might be some bad faith there if they failed to investigate, or hear evidence...
Have you heard back from your appeal?
Posted: Fri Oct 19, 2012 01:40 am Post Subject: car accident
my daughter had gotten into a single car crash this past friday night ..she was was driving her husbands car and she is currently not living with him and he doesnt have her listed as a driver on his insurance policy ..what can I do? :cry:
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