9 answers

Medical Insurance - Breaking the Bank with Denial of Claims

I have never felt so backed into a corner. We just got word today that our medical insurance with Humana is being denied. I did not go in for cosmetic surgery - I had a baby. My husband's company carries the insurance and when we were reading through the information about coverage, it says - patient pays "0%" for Dr after $1000 deductible. Well - they are now telling us they will only cover 80%. It doesn't seem like that big of a deal, but the grand total is $4800! That may seem like a lot to some of us and nothing to others. But, for a mom who has 3 kids (Thankfully a great marriage.) under 5 - it is a lot of money. ALTHOUGH - I would pay way more for the great son I now have

I am hoping someone can give me some advice on how to get Humana to take care of what is written on their information. Or how to get big companies to help out the small fries. We obviously are not rich - we are just trying to make it.

M. K.

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More Answers

I have fought so many insurance denials with a crappy small insurance carrier we used to have (it happens way too often) and I usually got what I wanted in the end. It's time-consuming and a very frustrating process because you get the run-around, but if you persist you hopefully won't have to pay more than the $1,000 you expected. When you call, ask to speak to a manager, or someone who can actually make a decision. Document your phone call in a log--date and the person you spoke with and what they said they will do. It will help hold individuals accountable and make things happen. Tell them what you want to be done (you may have to be little pushy and ask to speak to someone above them if they can't help you. If they say it can't be done, don't let them get off that easy. Ask them what they CAN do to help you), confirm what they will do and when it will be done by at the end of the phone call, and make sure they agree to call you when it has been done. Most likely you will have to follow up and call them instead of the other way around, but keep on it. Obtain their direct phone line/email if possible so you're dealing with the same person and they have more accountability. The squeaky wheel gets the oil. But be prepared for things to be dragged out. The appeals process, or any process with an insurance company for that matter, takes FOREVER with so many exacting requirements and steps.

Try to be respectful but be very firm. Don't buy their stories or runaround. Call them on it if they are changing their story, and refer to your notes. Let them know you are documenting everything, and "according to my notes when I spoke with you on such and such a date, we agreed you would do x. It hasn't happened yet, so I would like to know why, and when I can expect it to be taken care of." If you attack them (it can be so frustrating that you want to yell or cuss or spit nails) it will not motivate them to help you.

Start the whole process by telling them you have documentation that says patient pays "0%" for Dr after $1000 deductible and that you insist on them covering it after the deductible or that they give you an explanation.

Also, is the coverage handbook you are referring to current? I remember once I was looking at an outdated handbook, so my coverage had changed and I wasn't aware of that. So that unfortunately may be the issue.

1 mom found this helpful

I hear stories like this all the time. I am a mom of 2 young kids and work for AFLAC....yes that silly duck company. Good luck with the insurance companies...they are cutting costs left and right, raising premiums and deductibles. Business are also trying to save money and cutting their costs in their insurance coverage also by lowering their costs by lowering premiums and raising your deductibles.

When I was looking for a career change I just went to the AFLAC interview for "experience". I refused to sell insurance. I ended up LOVING the company and what it can do for people like me, you and anybody else. I could go on for days about how it changes peoples lives, but it helps with all the unexpected medical costs major medical does not cover. AFLAC pays a CA$H benefit to YOU! (I write it that way because it is true). Accidents, sickness, cancer, hospital plans (which covers pregnancy) and much more. I had my daughter and recieved over $1700.00 from AFLAC, which helped pay our out of pocket medical expenses and a few new outfits for her! About 4 months later my appendix ruptured and I was in the hospital for 3 days and I got a check from AFLAC for close to $3000. During that time, I had to take time off work, and that 3K sure helped pay the daycare, and a few bills we had lurking!
I don't want to sound like a cheesey sales person, but it is amazing what AFLAC is able to do for people like us who can't afford the unexpected medical bills AND it does not co-mingle with ANY insurance company. Major medical takes care of that, then you file with AFLAC and they pay YOU CA$H to be spent any way you wish.
I know you will say, I can't afford another bill a month...but can you afford your medical bills now? The policies range from $30-75 a month depending on the policy anad if you have it for yourself or as a family.

Feel free to email me if you want more information....I am still trying to find the "catch" and it has been over 2 years since I started with them.


Hi M.,
Yes, as Tiffany stated, you can beat them, but it does take a lot of persistant hard work. Let them know of the document you have that states the coverage. ALWAYS get the persons name you speak to, document the time and date and what they say. Keep a journal of notes. Hopefully, one of them will give you some insight.

Fax their document to them. I did so everyday. They would say they don't have it yet and I would tell them to go look at their fax machine because I just faxed it before I called. It did get to the point that they would put me on hold as soon as they knew who I was, but I finally told them to tell their directors I would not be calling again and the next time we would speak was in court because I had all the documentation and did my due dillegence to provide them with everything I had, which they should have had as well.

7 months later (from surgery), the doctors office receive payment. No follow phone call, just a payment.


My insurance didn't pay all of my bills when I had a baby either and my husband and I just didn't have the money to pay if all off at once. We were worried about being able to afford diapers, clothes, and all the stuff a baby needs and this added a bunch of stress. I talked to our doctor's office and the hosiptal and worked out a payment plan. I tried to talk to insurance office but they didn't budge. I am paying my daughter off in monthly payments that are interest free. I am sorry that I don't have any advice on dealing with the insurance but here is another option. Good luck and congratulations on the new baby!


Hi! I see your post was from awhile ago and you've received some great advice. One thing missing, however, is contacting the human resources department of your husbands company. Not only do they understand your benefits and compensation like the back of their own hands, it is their job to administer the plan. If there is a problem with the plan, they need to know about it. They also have an 'in' that you cannot get no matter what number you call nor how many times you dial it. I would find out who is responsible at your husbands workplace and approach him or her in a matter of fact way for help: first to explain the benefits, then, if you indeed have been wronged you could kindly request their assistance to help you and the company work out the issue. I strongly suggest making all these requests in writing (even just a formal email) as it will ease the workload of the employee who will have to put it in writing for the company anyway. Make sure to include details like your full names, dates, subscriber ID#, date of event, page numbers and even a copy of the page with the 0% info. Copies of the bills will also help.
Good Luck!

File a complaint- ask for their grievance and appeals department and be persistent- if they have truly changed their coverage- tell them you will call better business bureau and/or the media. Ins companies will back down if they have to - but if you dont fight they will run you over.

Hi M.,
I just wanted to mention to you that if your insurance doesn't cover it (after you have double checked everything and tried to work it out with Humana) you can also possibly talk to your tax specialist about how much medical expenses may be deducted from your taxes. I'm not sure exactly what your circumstances are, but I know that if your medical expenses exceed a certain percent of your income - you ca deduct it.

I hope this helps.

M. F.


I used to work in medical collections - trying to get the insurance companies to pay on patients claims. First make sure you are looking at your contract. Also, look at the explanation of benefits and see what it says you owe. The EOB is the paper that the insurance sends you after they deny or pay a claim. Also, you can look at the eob and see if something is being denied for a certain reason (maybe it was billed wrong) or sometimes the hospital may need to write off charges. It could be a number of things. I know if the total from the hospital was $4800 sometimes the hospital has a contracted rate and it will be reduced. I don't know if you have received the eob from the birth yet. I would contact the insurance company and speak to a supervisor for clarification. When you find out what is owed I would contact the hospital also and make sure that the amount the hospital says you owe and the insurance says you owe matches. Good luck!


first of all go through your contract with a fine toothed comb. may insurances quote different things in different paragraphs. it is against the law for an insurance to change the plan and rates without your knowledge. make sure they didnt send you an amendament later on that said it would only pay 80%. next get on the phone and be prepared to be on the phone for a long long time. dont talk to the the first person that answers the phone. tell them you want to talk to an upper level manager and dont bow down. you dont have to explain and detail to them just tell them you have a problem and yo only want to deal with upper managment. write down everyones name and what they said to you .it is also a good idea to let them know that you are trying to resolve this problem and if it cant be resolved yo will go through your states insurance board. tell them you only have this much time to resolve the problem and that stinging you along wont be acceptable. if in fact they only pay 80%, you need to go to the hospital and tell them you want to negotiate to pay the contracted rate. this is the amoutn the insurance would normally pay. for example if a hospital charges 100 dollars and the contracted rate is 35%( this is what most insuranceds pay), then you have the right to ask the hospital to reduce you part of the bill to the contracted rate. if you dont know about this they dont offer the information they just charge you their normal rates. also ask the hospital to give you an itemized bill. you would be surprised with the things they charge you for that you dont get. basically it goes like this. a nurse charts the supplies she used but if she has multiple patients she may bget some of the supplies charged to the wrong patient. then it goes to the ward clerk who goes through it and puts in charges for certain procedures. then it goes to medical records and then to the business office. there are so many people doing adjustments that sometimes thigns get lost or misconstued. sad reality but that is what sometimes happens. patiens usually get a bil that sys the total amoutn and nothing else . it is a paper saving thing and also too much and most patients dont question the charges. the charges are aoutrageous. i have a bill that chrges 15.oo for the medication and 165 for administration . which means that you are paying 165.00 for the syringe the alchol pad and for the minute that the nurse takes to give it to you and i guess of course for the lights and the water that you used while getting that shot. anyway. good luck

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