Projects and Disputes Case Studies
We have extensive experience successfully representing clients and families when insurance has denied coverage for a treatment or procedure or claims have been incorrectly submitted or processed, resulting in large medical bills. Examples of our work are described below:
Cost of Secondary Coverage
An ongoing client with the Insurance and Claims Advocacy Service forwarded an insurance renewal notice to us. The notice indicated that the premiums for her coverage secondary to Medicare would be increased substantially to $1440 per month or over $17,000 per year. We advised the client to not continue with the retiree coverage except for the dental plan and assisted her in selecting a Medicare Supplement and Medicare Part D Plan saving her approximately $14,000 per year.
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Adequate Retiree Health Coverage
A large company retained us to assist a retiring executive with his healthcare coverage planning, including enrolling in Medicare and understanding his retiree benefits. We learned that aside from prescription drug coverage, the retiree benefits were limited to a lifetime maximum of $50,000 per year. As a result, we assisted this individual in obtaining other coverage to better protect him.
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Medicare Enrollment
The daughter of a gentleman who became a client came to us when he needed surgery and his COBRA was expiring. The client had worked well into his 70’s and then taken COBRA. He had not signed up for Medicare when he should have. We advised the family that his best option was to have the surgery done prior to the COBRA expiring and to immediately register for Medicare Parts A and B.
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Pre-Existing Conditions
A company hired us to assist an executive they were attempting to recruit with healthcare coverage planning. The executive’s wife had been diagnosed with serious illness and was being treated by a number of physicians who did not participate with the prospective employer’s plan. The wife would not qualify for individual insurance due to pre-existing conditions. We identified the various options available to the couple to obtain coverage which would allow the husband to accept the new position and the wife to continue to be cared for by her doctors on an in-network basis.
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Healthcare Coverage after Divorce
We were retained by a divorced woman whose COBRA was expiring to review her health insurance coverage options. Due to pre-existing conditions she was not able to get coverage in the individual, private market. We worked with her and an insurance broker to obtain coverage for her through a business she had started.
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Healthcare Coverage Outside the United States
A financial advisor asked us to review the coverage of clients who had retiree coverage through an entity outside of the United States. We found the lifetime maximum of the plan to be disconcertingly low. When this information was brought to the attention of company executives, they decided the maximum was indeed too low and doubled the coverage for all retirees.
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Generational Healthcare Coverage Planning
We have worked with a number of families to review the coverage of several generations of family members. In each of these instances, a patriarch or matriarch has been concerned about coverage either because members of a younger generation are self-employed or have significant illness in the family or both. Such reviews have included medical, disability, long term care, and travel insurance issues for Americans and for Americans living abroad. One client remained employed after age 65 and was on his company’s plan. He wanted to understand his coverage options if retiring and how they would affect his younger wife. We assisted him with planning for his daughter who was about to graduate from college and no longer be eligible to remain on the company plan. We were also able to find better coverage at a lower cost for his domestic employees.
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Denied Claims/Out of Network Claims
We were retained by the family of a one year old child who was diagnosed with a brain tumor. All claims were initially denied by insurance citing a pre-existing condition exclusion. We successfully challenged the insurer with respect to this position. The next issue was that the insurer processed hundreds of thousands of dollars in hospital and physician claims as out of network. This left the family with hundreds of thousands of dollars in balance bills. We successfully appealed the out of network designation. After two million in claims had been processed, the family was only held responsible for the policy’s deductible.
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Out of Network Claims
Our client had colon cancer metastacized to the liver. Her doctors referred her to a tertiary center for surgery and other services that could not be provided within the network. The client’s plan processed these claims as out of network, leaving her with about $60,000 in balance bills. We appealed the Plan’s position and the Plan overturned the denial and reprocessed the claims.
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Approval of Services
We were retained by the family of girl who needed a bone marrow transplant as a result of leukemia. The Plan approved the transplant but at distant centers with which the Plan had a contract. The family wanted the procedure to be done at the center the oncologist recommended but this would have meant the transplant being done on an out of network basis. We worked with all parties involved. After a second hearing, the Plan agreed to allow the transplant to be done on an in-network basis at the desired center. This saved the family an estimated $100,000 or more.
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Denial of Services/Equipment
Our teenage client’s parents sought our help in obtaining approval for equipment to monitor glucose levels in diabetics. The insurer had put into place a convoluted, multi-step, difficult process to request approval and our request for approval was promptly denied. We appealed the denial and the Plan reversed its position and covered the equipment.
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Large Balance Bills
Our client had a very significant cardiac event from which she recovered. Months later the family was receiving very large bills from the cardiologist which were totally unanticipated. The client had very good coverage and her illness was clearly a life-threatening emergency. The family asked for help when the matter was sent to collection. Our review revealed that the insurance company had processed the claim incorrectly. The insurer reprocessed the claim and the patient paid the small balance which was her responsibility.
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Claims Denied
Our client with leukemia had obtained preauthorization for services at a major medical center. In spite of the preauthorization, the family was receiving numerous insurance statements on a daily basis showing services denied. When we reviewed itemized bills it became clear that the problem was a hospital coding issue and we appealed the denials. At the second level of appeal, the Plan recognized the coding problem and that they had been denying services they had originally approved. We worked with the Plan and the Center’s billing staff through all the reprocessing of claims.
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Long Term Care Claims
We received a call from the son and daughter in law of a woman in an assisted living facility who had advanced dementia. Their initial concern was that the pharmacy was no longer acting as though the mother had any drug coverage. In fact, the deceased husband’s retiree coverage had been eliminated. We assisted with that issue and a Medicare supplement. As part of our normal review, we asked about long term care coverage but the couple didn’t know if the mother had any. I asked that they search her files and a policy was located. The company originally indicated they would not honor the benefits due to claims filing deadlines. We successfully appealed that position and the company is paying the full $250,000 benefit.
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