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Action: Insurance procedures led to improper claim denial

Insurance procedures led to improper claim denial

Q: My wife and I, ages 84 and 88 respectively, were involved in an auto accident on Jan. 14, 2008. We were both taken by ambulance to the emergency room. I was released the same day, but my wife complained of chest pains and was admitted for two days of observation.

We received therapy for approximately two months at a clinic in Brooksville, which was partially covered by our auto insurer.

The problem is that now Medicare is denying payment of my wife's routine medical visits to our family doctor. Months after our accident treatment, Medicare is claiming that these visits are accident-related, and our bills remain unpaid since last July.

Albert Fremaux

A: "Unfortunately, this happens a lot in this industry," according to Gregory Flowers, manager of customer service and critical inquiries for Blue Cross and Blue Shield of Florida. Luckily, the denial has been reversed because of your persistence.

Flowers explained how claims come through and get processed at BCBS. Since Medicare is your primary health insurance carrier, claims are first sent to it and a decision is made whether to approve or deny the payment. This decision, along with the claim, is then passed on to your secondary health insurance provider, in your case, BCBS. The secondary provider then processes the claim according to Medicare's decision.

When your claim was sent to Medicare, somewhere in the paperwork there was indication of an auto accident. Medicare automatically denied it for this reason and BCBS followed suit.

"Whatever they do, we do, so we automatically denied the claims," said Flowers. The way to get a denial reversed is to resubmit the claim, explaining the reason for resubmitting, he added. This is exactly what happened in your case. When your resubmitted claim made it to BCBS, Flowers said, they acted by "correcting the denial and followed Medicare's payment strategy."

It took a long time, but full refund eventually arrived

Q: I have been trying to get a refund since July 2008 from Thomson Consumer Electronics for a defective VCR/DVD recorder.

After shipping back the recorder, waiting for Thomson to get it in stock and mailing in my proof of purchase, I was finally offered a refund. It was to arrive in 4 to 6 weeks. Three months after this offer and six months since my VCR/DVD recorder broke, I have yet to receive any compensation.

Barbara Hardoerfer

A: Thanks for letting us know you received your full $240.69 refund.

Natalie, a customer relations agent for Thomson, said that refunds are usually received six to eight weeks after requested. She said there was a delay in the release of your refund due to a "computer system transition."

Action: Insurance procedures led to improper claim denial 02/28/09 [Last modified: Tuesday, March 31, 2009 3:14pm]

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