Ahhh, the second of the insurance stories has trickled in and it’s a rip-roaring doozy.

Bodily mutilation
Kafa references
Indomitable and persistent consumer
Victory, snatched from the jaws of defeat, snatched from the jaws of abject incompetence.

Here’s a teaser line: “Then I got the surgery. Trust me, getting my face sliced up was the easy part.”

Tom’s letter, inside.

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Tom writes:

“Hi –

This will probably be one of the better insurance stories you receive. But you gotta read to the end because this thing ends like a good book.

In March 2003 I scheduled surgery for nasal polyps (ok, that part of the story isn’t very good). I called my insurance company, CIGNA, to get preauthorization for the surgery (or what they call a predetermination of benefits). I also requested and received a predetermination for the surgeon I was to use. Finally, I requested and received a predetermination for the hospital the surgery was to be performed at. In short, I did everything I could imagine to make sure I didn’t get screwed by CIGNA.

I got the surgery in late March 2003. When I checked into the hospital, I provided my insurance information and listened while the hospital verified it with CIGNA, described the surgery and the surgeon, reviewed the treatment history, etc.

Then I got the surgery. Trust me, getting my face sliced up was the easy part.

Precisely 30 days later, I called the hospital to ensure they had been paid. They had not. So I called CIGNA to ask why. CIGNA assured me payment in full had been approved and was scheduled.

Thirty days later, same thing. Payment was approved, there are no problems, you have nothing to worry about, the bill will be paid.

Thirdy days later, same thing.

One week later I call again (the plan at this point was to call them every week, and then every day, until they paid). At this point, however, the story changed. As Donald Rumsfeld might say, goodness gracious did the story change. I was advised – 97 days after surgery, approximately 120 days since surgery was “pre-approved” – that CIGNA wouldn’t pay one nickel of the hospital’s charges. That hospital, they informed me, didn’t participate in CIGNA’s plan and was unauthorized. I was politely informed it would be up to me to pay the $9700 hospital bill.

The volume of telephone calls that ensued over the subsequent 9 months would take far too long to describe, so at this point I’ll greatly condense things.

I contacted my doctor – was I crazy, or didn’t he tell me his staff had verified all this stuff as well? His staff informed me they had. In fact, the hospital they used was the only one in the region with the medical equipment required for this surgery. It wasn’t possible at any other hospital.

I called CIGNA back and told them. Well, yes, the CIGNA representative told me, perhaps we would have authorized treatment with that information, but you didn’t provide it at the time.

I asked her, well, the doctor also confirmed coverage at that hospital. In fact, the hospital itself confirmed coverage before AND after surgery. We’re not imagining this. We have names and times and badge numbers.

This, word for word, was CIGNA’s response: “Well, sir, it was a clerical error. You know, mistakes happen.”

A-ha, I thought. They admit it was their own fault!

I then called the Ohio insurance commission (the body that regulates insurance companies in Ohio). Very proudly I described the situation to a case worker. I proudly described CIGNA’s admission that they had made a mistake, that it was their fault.

This, word for word, was the Ohio insurance commission’s response: “Well, sir, it was just a clerical error. Mistakes happen.”

Yes, I replied, but it was THEIR error, not mine. I was politely informed that it didn’t matter – I still had to pay for it, not them. The only determination of benefits that matters, I was told, was the one they make when the get the bill. That is, AFTER the treatment has already taken place.

In other words, I did all my homework, crossed all my t’s and dotted my i’s, got badge numbers and predetermination-of-benefit codes, and made sure the hospital and doctor did as well – and none of it mattered. Not one bit. Nothing counts until they get the final bill. That’s when a binding decision is made. In Ohio, there is no way to ensure a procedure will be covered before you undergo that procedure. This, somehow, constitutes “insurance.”

Just to wallow in the Kafka-esque glory, let’s recap: CIGNA pre-authorized everything. CIGNA even told me that since the hospital I used was the only one available with the necessary equipment, they would have approved it if I had told them that fact. But I didnt’ tell them that fact because I didn’t know I needed to, because they told me they would cover it regardless. And they admitted it was their error, and they were terribly sorry. But they still wouldn’t pay. Think about that for a moment. Try to imagine how these clowns live with themselves.

So I filed an appeal. A few weeks later, I got in contact with a company in New Jersey that represents screwed claimants like me. I decided to let them file an appeal on my behalf, so I told CIGNA to cancel my appeal and I would resubmit it. They said ok. They even sent me a letter stating the appeal had been cancelled. A new appeal, prepared by this company in New Jersey, was submitted.

To condense this story even further, on FOUR separate occasions over the next nine months, CIGNA told me my appeal had been approved, and on these FOUR occasions when the hospital never got paid and I called CIGNA back, CIGNA told me that information was a “clerical error” and the appeal had NOT been approved. FOUR TIMES. FOUR FUCKING TIMES.

This story has a great ending – hang with me.

After eight months, my resubmitted appeal was denied. Terribly sorry, said CIGNA, but it seems the surgery itself wasn’t necessary, so we are considering demanding back the money we paid your surgeon, too. He may bill you. The approval for surgery (not the facility approval, but the actual procedure approval) was – wait for it! – a “clerical error.” That’s another $5000 or so I’m now on the hook for. In fact, I interpreted this message as a threat, an attempt to intimidate me from pursuing the hospital charges.

I was despondent. I gave up.

One month later, I get another letter from CIGNA. I couldn’t imagine what it was for – my appeal had been denied. Game over. I lose.

The letter says, we are happy to tell you that the appeal you filed on July 3 has been approved and payment will be made to your facility provider. Wha?!

Turns out my first appeal – the one I cancelled, the one for which cancellation was verified in a letter CIGNA sent me – was never actually cancelled. So two appeals were in the system. The second one was reviewed first and rejected. The first one was reviewed second, and even though it contained essentially the same set of facts, it was approved.

Terribly sorry. Clerical error. The bill’s yours, CIGNA.

See a pattern here?

The moral of the story is, NEVER EVER USE CIGNA.”

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