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]