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Complaint 0 of 0 in "Pre-existing Conditions"

Insurance Carrier: Golden Rule(provider) / United Healthcare
State: Virginia

Consumer Complaint:

They decided that my claims must be pre-existing and have decided not to cover anything, but they are still taking out funds every month to have insurance with them. They are not totally correct of the so-called pre-existing condition. I recently was diagnosed with low testosterone and they said its genetic, so they cannot cover it because it is a pre-existing condition. Now I owe thousands to doctors. I recently had a lump on the back of my head that the doctor said was an infection that I was able to get taken care of with medicine.

The insurance said that they cannot cover the issue because it is a pre-existing condition. They said more-so that I lied on my enrollment form 2 years ago about ever having lumps and bumps on my head? Never happened. I was recently diagnosed with Anxiety and depression which I have been taking medication for.

My family doctor which I was referred to by my current insurance company said that I need a psychiatrist for evaluation. They psychiatrist put me on medication which the insurance was covering up to a couple months, and then my psychiatrist was not getting paid for several months. My family doctor wasn’t getting paid either, because Golden Rule had to review my files which took them over 6 months to do. After the 6 months and more treatment they wrote me a letter that said they have reason to believe that my issues are pre-existing due to my counselors notes(by the way, the counselor was found through my insurance carrier whom I am with now). My counselor I chose to see 2 months before my insurance started was counseling me with OCD (obsessive compulsive disorder) and marriage counseling. My anxiety with depression followed after the cure of OCD. But they have chosen not to believe me. Even though they were not paying my bills for 6 months, they were still deducting my premium each month. Now I owe even more thousands because of this. They sent me a letter saying that I lied on my application about not smoking. Before we got the insurance, we had quit over 1 year before that. They are saying I lied about that too, and have raised my premium and demanded $400 back pay or else they would drop us from insurance. I paid it so I can fight this and also have some sort of insurance. My psychiatrist put me on 4 different types of medicine plus Effexor. The side effects to this medication causes weight gain. After my insurance found this out too, about the weight gain, they said I lied on my application from 2 years ago about my weight, and that’s why they have had to adjust my premium. They say my weight is a pre-existing condition. I have pictures of what I looked like 2 years ago before starting these medicines to prove that I wasn’t 70 lbs. heavier. See what you can do to help me. My uncle is an Insurance lawyer that works for an insurance company that says Golden Rule is in trouble right now with doing these same things to others. He told me to contact someone like you first. Please help me.

Insurance Expert Answer:

Two separate issues. A. Is the company correct that the condition is pre-existing? If it is, and your coverage has a permissible exclusion for pre existing conditions, you don't have coverage for THOSE conditions and indeed, if you misrepresented your health on the application, the company could rescind the coverage. If the company is wrong, and the conditions were NOT pre-existing, and the company wrongfully denied the claim, you have a basis for complaint and maybe a lawsuit against them. One issue is how debatable is it, and was there bad faith involved. That often requires a law firm with real experience in filing claims against the carrier as very often there are patterns that someone inexperienced misses. (If you provide the details I could sent it over for a free evaluation to a law firm that has filed many cases against Golden Rule and is familiar with their wrongful denials.) B. If the company is continuing to charge premium and you don't want to continue the policy, that's a separate issue. Tell your bank to reject future charges, and write a letter -- with a stamp -- to the CEO of the company complaining. I can't say if there is any chance of recouping past charges as if you got some insurance coverage -- even if the pre-existing conditions were not paid for -- there was value received. I am going to send this on to an insurance law firm that has significant experience and has been handling multiple bad faith cases against Golden Rule. I will ask that a lawyer from that firm contact you IF he or she wants/ needs more information and/or thinks there is a basis for a claim, and if Virginia law is sufficiently favorable to make it worthwhile to raise bad faith issues or there are sufficient damages beyond the thousands of dollars in claims they denied. The law firm will NOT be back to you if it is not interested in the case for a variety of reasons. Please understand that the amount of money involved in the denied claims, standing alone, while meaningful to most people would not make it sufficiently attractive to a law firm. Please also consider the possibility of small claims court.