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Insurance Carrier: Cigna
State: Kentucky

Consumer Complaint:

My nine year old son started receiving allergy shots. He has severe allergies. I was told by a Cigna representative "Jessica" on 6/23/08 at 2:05pm that the bill I received from the doctor's office was all covered. I owed nothing out of pocket. Fully covered. On 7/11/08 when the bills still had not been paid, another rep. Demaris said my sons allergy shots "were not covered", that the $19.94 per shot fee did not count towards my deductible, and that Cigna would not pay any amount towards shots. Why did I go from fully covered by Jessica, to not covered by another rep? If I pay $19.94 per shot why does that not count as out -of- pocket expense and go towards my deductible? I feel if Jessica made an error, Cigna should still pay. I was told I was fully covered, now that we have been getting my son allergy shots since April, they are not going to pay. Any advice is greatly appreciated.


Insurance Expert Answer:

The terms of the policy - not what someone in an 800 number call center says - almost always govern. If the woman said they were not covered and the plan said they were, you're covered. The reverse is also true.

I have no idea what the policy says. I urge you to read the full plan and all descriptive material. If you find support to show it is covered, cite it. If your son needed the shots, it's not as if you would not have given them to you if they said they were not covered. But if you would have had them given elsewhere, then you might have a more persuasive argument for getting them covered until they said they were not covered.

But only the CEO of the plan might waive limits; a polite letter sometimes works wonders.