Hi Everyone:
 
I suspect the following story will be familiar to some people.  The story
goes like this:
 
In September 2002, Rusty had a unilateral adrenalectomy.  VPI paid $751
for the claim (I know, I should be thankful I got that much!).  On August
4, 2003 (in the same policy term as the first surgery, which is important
for later), Rusty had his other adrenal out (along with his spleen).  I
filed the same claim (with the secondary splenectomy) earlier this month
and I got a check for $168.  When I called VPI to ask about the
discrepancy, they stated that since it was the same diagnosis/treatment
as the first incident, the two were "linked" (considered as the same
incident) and thusly I only got what was "left over" from the first claim
(which brought up a whole new set of questions, but I digress).  I asked
the rep where the language was in my benefit schedule that indicated that
two incidences could be "linked", and she indicated that "It's not in the
benefit schedule, but it's done on a case by case basis."
 
To shorten up this long story, my option is to take what I can get, or
file a claim review.  My question is this: has anyone done a claim review
for this type of situation, and what was the outcome?  I'm trying to
decide whether or not it's worth the time and resultant blood pressure
spike to fight with these people.
 
And before anyone goes there, yes, I realize that insurance companies are
in it for the money and that it would be foolish of them to crank out big
benefit checks for policies with premiums of $14 a month.  My whole point
in doing this is that this linking policy is NOT explained in the benefit
schedule.  If the linking policy had been in the benefit schedule, I
would have chastised myself for not reading the fine print more closely
and dealt with it.  However, the fact that they're not notifying people
of policy conditions and just whipping them out whenever they feel like
it is what bothers me.
 
Someone else may have mentioned this, but I thought it bore repeating.
Rusty's policy term that BOTH surgeries fell under was from 8/27/02 to
8/27/03.  The benefit schedule that came with the new policy term papers
that begins AFTER 8/27/03 has a new exclusion: both medical and surgical
treatments for endocrine neoplasias (and associated splenectomies) are
excluded.
 
Feel free to email me privately with any information if you'd rather not
post to the list.
 
Thanks!
 
Laura Martinez
[Posted in FML issue 4257]