AETNA - Beware!!!!

[NormanJ5442]

If anyone has AETNA, you should BEWARE any information you get over the phone from their reps. I called them twice before my surgery to verify that it was covered, and they said yes both times. My share was supposed to be $1200. The doctor’s office and hospital ALSO confirmed with Aetna that it was covered and that I would owe $1200. Flash forward 1 week later — Aetna suddenly says my plan does not cover Erectile Dysfunction. Why didn’t they tell me this last week??!! Now I’m looking at a $75,000 bill. No idea what I’m going to do.

[Txagq8]

You say you have no idea of what you’re going to do.

First things first: don’t panic, don’t freak.

If the insurance carrier told the surgeon it was covered prior to the surgery being performed, then I think you’re golden.

You don’t say what state you’re in but in Texas that most likely would be viewed as an oral contract and is enforceable.

You don’t say who the surgeon was but there are many high volume guys who do the whole thing (incl anesthesia, hospital, device, surgery, and follow up) for between $17K and $25K. I can’t imagine any scenario where you pay $75K.

It’s a shame they do it this way but medical care is priced like a new car only worse. There’s the sticker price then there’s a lower value which is what gets paid. As an example my doctor has a self-pay price of $17,200. (It might have gone up). My bill was $53K. The insurance paid him $19K. Everybody was happy.

You might need to consult a lawyer. He might need a sworn affidavit from whoever it was in the surgeon’s office who was given the go-ahead by the insurance carrier. Even if your policy contains an exclusion for ED related issues that sort of thing changes….so if they were contacted and said yes they would legally incur liability.

In the meantime: pay whatever your normal co-pay would be. Don’t sweat this. You’ve had your surgery, it’s done. Now you need to focus on healing and starting to cycle and getting back to normal life.

It’s not like the surgeon’s going to sneak into your home, chloroform you, and remove your implant.

I hate to pay lawyers. But sometimes it becomes a necessary evil. If it were me, I would let the surgeon’s billing office fight it out with AETNA for a while.

Someday, someone is going to find an insurance carrier who will pay to put an implant into a FTM transgender person while denying coverage to a male with ED. At that point in time some shifty lawyer is going to strike it rich with a class action discrimination lawsuit on behalf of men who were discriminated against for having a disability.

I hope you don’t think I’m treating this lightly but I’ve fought these battles myself. Concentrate on healing up. Don’t sweat this right now. If someone calls wanting money just take Nancy Reagan’s advice and just say no.

[LastHope]

Aetna and Cigna are notorious for canceling coverage just 48 hours before surgery or for expertly putting patients through a frustrating "appeals" process. In fact, one high-volume billing office I was in touch with was so certain of denials that they refused to even submit a claim and started a conversation about cash pay option. Hopefully, your billing team re-negotiates the costs, and you receive a reduced bill of around $20K after the so-called "insurance adjustment."

[JohnHC]

I have UMR, pulled the same stunt on me. Mine was worse in that my implant failed needing revision and after confirming before the original and the revision surgeries that both the surgery and device were covered they waited till after the second surgery to notify me they weren't paying. Since then second implant has failed so need a third surgery, appealed and got them to pay previous surgeries but I'm on my own for this revision.

[Txagq8]

Check the laws in your state.

If you get the self pay down to around $20k, that’s the upper limit for Texas small claims.

The process is simple. Send a demand letter that the insurance company reimburse you (the amount of self pay, needs to be less than $20k), give them 30 days, send it registered mail.

At 30 days (or sooner, if they send you a denial) go to the Justice of the Peace and file a civil lawsuit against insurance carrier. This will cost $150 to serve the company.

45 days after they’re served you and insurance gi to trial in front of JP or jury. Your case is you paid insurance premiums, they told surgeon you had coverage, you had procedure done, now they’re refusing to pay.

I’d lay 95% odds that they cut you a check long before you get to court. It’s going to cost the insurance carrier legal fees to go to trial. This kind of publicity isn’t good advertising for them. And a Justice of the Peace is very likely to go with doctrine that if a representative or agent of company said you were covered for this, then they have accepted liability and after it’s done it’s too late to change their minds.

You definitely need to check laws pertaining to small claims where you are. If you can use that tool, however, it is fair, fast, and relatively inexpensive. The insurance company’s lawyer staff can’t drag it out and cause you to have to eat a ton of legal fees in order to discourage you.

In my retirement age I find that what a lot of organizations do is try to make you miserable. My goal is to make sure everyone involved is equally miserable.

[Gt1956]

Check the laws in your state.

If you get the self pay down to around $20k, that’s the upper limit for Texas small claims.

The process is simple. Send a demand letter that the insurance company reimburse you (the amount of self pay, needs to be less than $20k), give them 30 days, send it registered mail.

At 30 days (or sooner, if they send you a denial) go to the Justice of the Peace and file a civil lawsuit against insurance carrier. This will cost $150 to serve the company.

45 days after they’re served you and insurance gi to trial in front of JP or jury. Your case is you paid insurance premiums, they told surgeon you had coverage, you had procedure done, now they’re refusing to pay.

I’d lay 95% odds that they cut you a check long before you get to court. It’s going to cost the insurance carrier legal fees to go to trial. This kind of publicity isn’t good advertising for them. And a Justice of the Peace is very likely to go with doctrine that if a representative or agent of company said you were covered for this, then they have accepted liability and after it’s done it’s too late to change their minds.

You definitely need to check laws pertaining to small claims where you are. If you can use that tool, however, it is fair, fast, and relatively inexpensive. The insurance company’s lawyer staff can’t drag it out and cause you to have to eat a ton of legal fees in order to discourage you.

In my retirement age I find that what a lot of organizations do is try to make you miserable. My goal is to make sure everyone involved is equally miserable.

I think your advice is sound. It might help to have something showing that they initally approved it.

In some states, the lawyer can ask to have the case referred to a normal court from the small cliams court. That pretty much kills it for the little guy. I.E. you need a lawyer.

A woman cut my wife off short on a lane change while she was in Las Vegas Nv. Our F350 just got a bend in the front bumper. Her rice burner had more damage. She retained a lawyer & sued us claiming my wife turned into her. But that would of been a "pit maneuver " like the police use. The rice burner didn't spin out. In the long run our insurance gave her $17k for damages & "injuries". I didn't think the girl did so well. Maybe up to 50% to her lawyer plus fix her Toyoda. My wifes first take was the girl went to look at her car first before checking on a child in a car seat. Insurance rep told us that these things are normally paid quickly. Irony is, girl got into a minor accident less that a year later.

So smallish claims are paid based upon a nuisance factor. I think this $17k claim supports your advice. Corporate lawyers might make $500 or more per billable hour. $20k goes fast.

[Txagq8]

Thanks for the info gt.

Once the plaintiff has filed here. And papers are served, the case will be heard in small claims.

The defendant can appeal it to county judge or counter sue in district court but that’s not quick, it’s definitely not cheap if you’re a hospital paying lawyers….and the overturn rate for JP court is surprisingly very low.

Insurance carriers and the government have worked together to make it almost impossible to get what you want, let alone what you need. So there is value added by anything that can be done to make the bastards as miserable as possible.