Complaint 15 of 16 in “Claim Denied / Delayed in Whole or Part”

Consumer Complaint:

My insurance will not pay for a CRNA and anesthesiologist. They are stating in a letter that they will not cover both. I can send you a copy of the letter. I believe it is a state law in MN that you must have a CRNA monitoring you as well as an anesthesiologist providing his services. They are claiming a duplicate service. I had this same problem in Jan. 2008 and in writing a letter of appeal, they paid. Now they are telling me that my state Deprtment of Insurance should be contacted for assistance. Please may I get some assistance from you to help me resolve this. It is an out-of-state company and because in IN. this is not required to have both a CRNA and Anesth. they denied the claim in Jan 2008 and by writing a letter to them they paid it. I am needing your assistance to clarify why they paid in in 1/2008 and are now claiming they have no documentation to support that this is medically necessary-when in our state is is required to have a CRNA and an anesthes.

Insurance Expert Answer:

We can not get into this involved level of detail with multiple state policies and varying state laws with some unusual provisions for an amount this small.

If your plan is private employer sponsored, and subject to ERISA, the terms of the plan apply and MN state law generally does not prevail. If it is an ERISA plan there are strict deadlines in terms of appeals within the system.

Do what you did last time and hope it works again.