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Health plan review panel clears bills

I have been a member of PCA Family Health Plan Inc. since November 1995. In January 1996, I had a Well Woman exam and a mammogram. I was healthy and cancer free.

In February I went for my checkup again and a suspicious mass showed up on my mammogram. After a sonogram followed by a biopsy on March 21, I was diagnosed with breast cancer.

On April 30, I had a mastectomy and reconstructive surgery. I was in the hospital for two days. PCA approved every step of the way.

Three weeks after my surgery, I was contacted by the hospital and told that PCA was not paying. My insurance company apparently was checking for pre-existing conditions, and it also said I had not sent in the authorization release form.

I had received a form a week before my surgery that I sent back the next day. I called PCA and got another form on May 29, made a copy and sent it back.

On June 12, PCA again said it did not have my form or my doctor's forms although my doctor had sent them. We both sent them again. This time I sent two to Miami and one to Tampa by certified mail.

Now I find that they still have not paid for either the biopsy or the surgery. The pathologist has now added his bill for service rendered in March to this lot. In addition, PCA claims my medical providers did not get approval for two days in the hospital.

I have had no success trying to resolve this. I called PCA, and someone was supposed to call me back the end of July/beginning of August. It never happened.

I am a single, working mother going through chemotherapy. I need your help. Bette Hewell

Response: On Aug. 25 we heard from Sherri Mack, central region grievance coordinator for PCA Family Health Plan Inc. in Tampa that your grievance had been forwarded to the grievance committee for investigation and resolution.

We heard again from Mack on Oct. 22. The grievance committee reviewed your complaint and found that payment was held up while your medical records from the hospital were reviewed to determine if you had a pre-existing condition.

Mack said the review indicated the condition was not pre-existing and the committee has recommended that the bills be authorized and paid. The issue has been forwarded to the claims department to be satisfied accordingly.

Mack said PCA hopes that this explanation is helpful to you. PCA continues to wish you the very best in health care. At PCA Family Health Plan Inc., complaints from members are taken very seriously, she said, and PCA appreciates you taking the time to communicate your experience.

Off the hook

I bought a Mitchell Fishing Reel in April. You could send a check for $5.95 to receive a 5 foot 6-inch UL spin rod, which I did on April 15. I never received it. My check was cashed, but no rod was sent. I wrote but never heard a word. I would really like to have this rod. Virginia Cheshire

Response: Dick Hodder of Johnson Worldwide Associates in Binghamton, N.Y., said the company made a mistake. It did receive your order, entered it into the computer, cashed your check and then failed to send you your Mitchell ultra light fishing rod. To add insult to injury, it failed to respond to your letter of inquiry.

Hodder said he does not know how this happened, but the company is trying to improve its system of order processing so that this will happen with less frequency.

Most importantly, Hodder said your rod is being shipped via Federal Express. (We trust you already have it.)

Hodder apologizes for the experience you had with Johnson Worldwide Associates and hopes that the fishing pleasure you will have with its products will ease your frustration.

Action solves problems and gets answers for you. If you have a question, or your own attempts to resolve a consumer complaint have failed, write Times Action, P.O. Box 1121, St. Petersburg, FL 33731, or call your Action number, 893-8171, or, outside of Pinellas, (800) 333-7505, ext. 8171, to leave a recorded request.

Requests will be accepted only by mail or voice mail; calls cannot be returned. We will not be responsible for personal documents, so please send only photocopies. If your complaint concerns merchandise ordered by mail, we need copies of both sides of your canceled check.

We may require additional information or prefer to reply by mail; therefore, readers must provide a full mailing address, including ZIP code. Names of letter writers will not be omitted except in unusual circumstances. Letters may be edited for length and clarity.

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