Insurance Company Denied Claims – Story

I am a male who is 51 years old and a father of three teenagers.

I went through a preventive Colonoscopy and Endoscopy after my gastroenterologist discussed over the phone the procedure with the assigned doctor from Coventry, my insurance provider, prior to the procedure being performed.

Now, Coventry is denying the claim. They are not complying with the Affordable Care Act. The reason I went through the procedure because of their approval and because of the information on the Affordable Act. If they did not approve it, I would not have done it.

Do you have any resources that I can use to demonstrate to Coventry (or any insurance provider) that this is incorrect?

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Three times in calendar year 2016 I called my insurance company (Ambetter) to make sure a particular thing would be covered BEFORE I went forward with it, each time they assured me it was covered in full, and in each case I received bills from an “in network” provider. The total portion I paid exceeded my deductable and max. out of pocket expenses, but Ambetter always has some excuse as to how that particular bill is my responsibility. How can they get away with telling me on the phone before hand that something is covered in full, but I end up being billed anyway?? (example… colonoscopy was to be completely covered, but I have to pay over $545 for anesthesia.


This insurance system is a mess, whenever and wherever we try to use it, the answer is the same, we don’t accept Obamacare. We bought Humana insurance HMO, at this moment all we’d gotten is to lose our money. Where can we go to claim??? It looks like a fools trap.


Any insurer who sells you a plan will be able to provide you with a list of healthcare providers that are in their network.


I have this insurance company also. I have had them for over three months and have yet to get a copy of my policy; and I’ve called them three times. I finally got a copy of my card after three months, but still no policy, but I sure get my bill from them each month. They do not pay on anything until the deductable is met. I’m stuck with them until October of this year, I can’t change insurance untilo then. Waste of money, this company can’t even seem to mail your policy and cards to you. Pretty bad.


This is one of my major concerns about insurance -companies denying claims!; and/or after-the-fact stating a cost is covered at a different ratio than expected. Being in a situation where a procedure, test or medication is necessary; then learning later that the coverage is different for some minute reason or that coverage is not available.


Did your gastroenterologist bill the insurance company with a preventative code? If you had a history of problems, then it would’nt be covered by the Wellness/Preventative Benefits. You need a copy of your health insurance policy, or better yet, get you insurance company on the phone and conference in coventry. I work in insurance (for one of the big ones) and that is how I would/could handle your situation.


Covered benefits and networks should be information that is provided by your insurer. It’s important to check with your insurer that a service and specialist are covered under your plan, and at what cost sharing amount before being treated in non-emergency situations.

That being said your best bet is to appeal.

As a rule of thumb insurers may deny claims and doctors may code things in an unfavorable way, but both of these things can be reversed with first a phone call, and then if not an appeal to the insurer. Appeals need to happen ASAP so you don’t miss your window of opportunity.

Essentially your insurer created the plan, your insurer approved the treatment, it’s on your insurer to make good now, and if a phone call doesn’t help that process along an official appeal just might.

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