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Insurance Carrier: Celtic Insurance Company
State: Ohio

Consumer Complaint:

Celtic Insurance Company of Indianapolis, IN refuses to pay for a procedure it claims is not covered by my policy. Their reason code on my explanation of benefits is 286 D24 stating, "The service submitted for this charge describes an automated test which does not have a professional component. Therefore, this is an ineligible expense." My complaint is that I have no control over this type of procedure. It isn't reasonable to classify such a procedure as "automated test which does not have a professional component." Two questions are at issue. First, a patient has no method to determine which procedures are automated and no knowledge to deny the use of such a procedure. Secondly, even though a procedure (e.g. blood counts) may be done by a machine, it is unlikely that such a machine can be operated correctly without an operator with professional training. Even the interpretation of the results from an automated procedure are evaluated by a professional or ultimately utilized by a professional to establish a condition, diagnosis, or treatment plan. Thus, such a procedure has a professional component.

Insurance Expert Answer:

While I agree with you, and know that an MRI is also an automated service and medicine is becoming more automated, when tests are ordered by a physician and reasonable they should be covered by a comprehensive medical/hospital policy, I'd have to read your policy to understand whether there is something in it that gives them a specific basis for the denial and thus whether it may be justified. I suggest you write a polite letter to Celtic's CEO and express surprise at the denial and see what happens.