The great thing about this site is the wealth of knowledge of it's members, I've taken alot and have tried to give as much back. Today I'm in an expensive situation that I need help with. I don't know who to ask anymore.

This past spring I had a near death experience and was saved my a great hospital staff and a wonder drug, TPA. Even though I called the insurance company before I went and went to an approved hospital, my insurance company is refusing to pay for the ICU stay because only the emergency room was approved not the ICU ward. The fact that I was in critical condition and on a breathing machine is irrelevant they tell me. The rule they have is that I have 2 business days to inform them, I was in ICU for 5 days. They expected me to call them from the ICU ward and inform them I was moved from the preapproved emergency ward to the hospital ICU ward is the best I can understand. I've already had one appeal and lost. I'm now preparing for the second appeal, with a lawsuit as my last resort.

Does anyone have any experience with filing appeals? Any advice I wholeheartedly welcome.

Let your lawyer handle it.

Sheesh! This is a job for Michael Moore.

Seriously, I'm sorry I can't help.

Thankfully I live in a society that values its citizenry enough to provide health care.

Bluelight, I discussed your post with someone "in the know" (attorney) and was told the following:
TPA is used for strokes, since you were iniitially given approval by someone for admittance to the emergency room, a person in serious condition isn't always able to contact anyone after admittence. Also, it may not have been safe to transfer you to a different facility, and you weren't in a position to decide that being in the medical situation (emerg) at the time. It appears that with a good attorney you should have no problem getting an appeal favorable to you, might take some legal wrangling tho......good luck.
As an aside, if this were to occure in the State of Texas he was sure you could win your appeal, apparently different States somtimes have different rules, even when dealing with the same carrier. Good luck

Besides working with an attorney in preparation for a lawsuit, I strongly suggest you report the incident to the appropriate regulatory department in your state (insurance commissioner, etc.). The situation you outline is absurd. If you were in California, the insurer would get hit like a ton of bricks for pulling something like that. You might also want to consider contacting your local newspaper, if they have "consumer rights" column of some sort, saying you have a juicy story for them to jump on. The insurer would hate all the bad publicity that would generate. Consult your attorney before doing so though.

An attorney will cost you $$$. Before you hire one, read the insurance policy / contract. There's always an appeal process. This happened to me. I filed a written appeal asking for re-consideration of a denial of coverage. I sent my written appeal via registered mail. In about two weeks, I got a letter from my health insurance carrier extending coverage.

Usually the denial is made by some underpaid clerical staff who is just following the rules and not paid to THINK. You just need to get past the first layer and get the attention of someone in the insurance company who is paid to THINK.

You should also file a complaint with your State Insurance Commissioner.

Again, don't hire an attorney (unless you've got money to burn) until you've exhausted all avenues of remedy.

I believe you live in AZ? If so, here's a link to the AZ Dept of Insurance: http://www.id.state.az.us/consumerassistance.html

Thank you all very much. I have gotten great feedback and its comforting to know others have been here before and won. I am going to file the 2nd appeal and will continue with a law suit if I have to. I feel like this is a high stakes poker game and the pot keeps getting bigger and bigger with every card played. And I have 2 cards left to play. Yes, I do live in AZ the hospital was Banner Desert the insurance co was Humana.

Bluelight, follow up on/with the Doctor that had to get the approval prior to administering the TPA, and go from there on your appeal as we discussed via PM.

Bluelight: This probably goes without saying but unless and until you get a lawyer, make sure you meet every deadline for your various appeals and any subsequent lawsuit. Failure to meet these deadlines likely would shut you out on any compensation irrespective of what otherwise would be the merits of your case.

Surely the hospital must also be filing appeals and screaming bloody murder. To retroactively deny an emergent hospitalization is absurd and unconscionable. If your second appeal is denied you could likely get a jury to award some pretty big punitive damages against your insurance company . After a life threatening illness they are putting unreasonable stress on you for sure.A very sympathetic case for jurors to get their hands on.

BTW Copperfieldkid

TPA is relatively rarely used for strokes but very frequently used for heart attacks. Never ask a lawyer for medical advice .

Khun Mor: You are right about punitive damages although the opportunity to get them, and whether they would amount to much, would depend on the state. I'm not sure what the current regime is in this regard in Arizona.

This may be particularly relevant to the decision when to obtain a lawyer. Generally, once you have to hire a lawyer in a personal injury or insurance claim case, you are then going to end up with signficantly less than if you had settled with the insurance company for a fair amount without a lawyer (owing to the lawyers' fees). But this arithmetic can change when there is a reasonable chance of getting punitive damages.

Having said this, Americans are overly influenced by the media reports of significant or excessive punitive damages cases. In fact, it is not that common to receive punitive damages, and that goes doubly for jurisdictions where the jury pool may be conservative. It is, however, a bit more common against insurance companies than other defendants; at least that is my impression.

One editorial comment. Alot of people in the U.S. have turned against the notion of punitive damages based on some of the excessive awards that in the past were reported by the media. But things change when you hear about situations such as Bluelight's. If there were no punitive damages, what real incentive would insurance companies have to settle any cases since the worst that would happen is they would have to pay out exactly the same amount if and only if the consumer went to the trouble of obtaining a lawyer, having a trial, and so forth. Although I suppose a free market type could argue that ths would put that particular insurance company at a competitive disadvantage relative to other companies (and I would concede this might play a small effect), this latter factor, which would be rather indirect, would still not come close to leveling out the playing field since each company would still stand to save alot of money by making it difficult for their insureds to collect. Punitive damages are meant to change the incentive structure so as to keep insurance companies honest, so to speak. The trick is keeping punitive damages sufficiently reasonable so as not to alter the incentive structure to one that favors the consumer so much so that insurance companies end up paying many frivolous claims so as to avoid the possibility of debilitating punitive damages awards.

>>>To retroactively deny an emergent hospitalization is absurd and unconscionable.

The insurance company doesn't see it that way if all they look at is the bottom line. That's the big problem with having competition in the insurance business - the only way to offer lower rates than the next company is to pay out less - be that in claims, office expenses, personnel costs, etc. Competition to reduce prices in the insurance business almost guarantees that these sorts of things will happen. This is where gov't needs to step in and level the playing field, by making such ridiculous restrictions unenforceable.

Thank you everyone for the support, advice, and help. I recieved a letter yesterday granting my appeal.

It states:
The approval of your appeal is based on the information provided by the hospital administration staff showing record that indictes a call was placed April 14, 2007 in attempt to preauthorized your emergency admission. It appears there may have been some confusion in this process as the record only indicated a tracking number (xxxxxx) and there is no evidence that completion of the preauthorization was obtained. ya ya ya ya However, due to the admission and call records retained by the Hospital, a one-time exception has been approved for the medical services in question. ya ya ya ya

No new information, they had everything from the very beginning. They are just pricks. Case closed! Rio in 3 days! It's party time!!!!!!

Happy to hear this worked out for you, at least in the end.

Bluelight,
good to see your following thru and being persistant with your appeal was successful!