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Insurance Carrier: BCBSIL
State: New York

Consumer Complaint:

Insurance company has denied a claim for services which I am fully covered (emergency service). Company states it denies the claim because the service was not emergency medical care; yet it gives no reason why it thinks that and the visit was undeniably an emergency. The hospital treated the service as an emergency and the triage nurse prioritized my case upon arrival at the hospital ER. All I know is that I was in severe pain and could not walk when I went to the emergency room. I didn't know at the time I had a near herniated disk with narrowing and arthritis which was causing such excruciating pain, but that was the reason, and had I called my doctor he would have told me to go to the ER as he and thousands of other doctors in NY don't work on Saturday. It is not my fault that BCBSIL does not have a clinic on the plan.


Insurance Expert Answer:

This seems to be a simple factual question: was your situation an "emergency" within the definition of the term in the policy language or the commonly accepted meaning of the words used in the policy? Emergency room visits are frightfully expensive and carriers do not charge enough or want to pay for the extra costs unless there was an emergency as defined. One's own definition is not sufficient, and the fact the triage nurse had you avoid a long wait is not either. You need to prove that it was what the policy deems an emergency, and I suggest you marshal your facts and appeal to the carrier with proof. A letter from the doctor saying he would have ordered you to ER would be helpful.