Claim Denied!!!

My fiancee recently got health insurance through his employer. We were aware of the pre-existing condition exclusion. He has arthritis and high blood pressure. He made an appointment, but NOT for either of those conditions.

One leg was swollen from his foot to his hip - not just the joints. His thigh about 1/2 way up was 2 inches larger than his other leg. His calf was 1 1/2 inches larger. This had never happened before. The doctor thought it was a blood clot. He sent him to the hospital for a vascular test.
Before he left the doctor's office, he was given an EKG based on his family history.

The doctor ordered blood tests at the hospital. He did not say what they were for.

A follow-up appointment was made the next day. The vascular test showed that he did not have a blood clot in his leg. THANK GOD! The doctor told him to come back in 6 MONTHS. I was pretty shocked that he was not doing anything about his leg. I asked him what caused it.

He said -sometimes people have a chronic thing like that, maybe Gout. I don't know why he said chronic. It had never happened before.

Now my fiancee's health insurance is denying the claim - the whole thing! Reason? Pre-existing condition, arthritis! I am disputing it, but I need some info from the doctor's office and they haven't called me back yet. As far as I'm concerned the cause of the swelling was undetermined. My guess is that he wrote in his report that its arthritis.

Meanwhile, my fiancee is having severe pain in his hip. THIS time it probably is arthritis. He can't go to his doctor because he has a balance due!

I would go to another doctor. There are other reason for the swelling, and there is medication for gout. Do not let him brush you off. I would go to the office and wait until I could talk to him face to face.

Definitely seek a second opinion on this. He may have to pay out of pocket still, but second opinions are always better. Especially if his original doctor is not giving him proper information, or told its something like gout and wrote it up as arthritis.

also to ensure a good second opinion, ask around about a good doctor. Testimonies are better than just picking one on a whim

Sorry, in my attempt to be concise, I forgot to let you know that his leg is better now. The appointment was last month. His leg was better after about a week. Its his hip now and I'm pretty sure that that IS arthritis.

His hip is so bad that in the morning he can't walk around the house without holding onto furniture. We may go to a different doctor for that since we would have to pay anyway.

If anyone with arthritis has had sucess with fish oil or the glucosimine combo, or any other natural alternative please speak up. I know the medication he's on isn't good for him.

Originally Posted by lunasmom

Definitely seek a second opinion on this. He may have to pay out of pocket still, but second opinions are always better. Especially if his original doctor is not giving him proper information, or told its something like gout and wrote it up as arthritis.

also to ensure a good second opinion, ask around about a good doctor. Testimonies are better than just picking one on a whim

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I wish I could take him to our vet. I really don't know anyone who says they have a really good doctor. Mine has been good so far, but I have only gone to him for minor things. IF (and this is a BIG if) I can talk him into it, he will go to another doctor. Unfortunately, I can't just put him in a carrier and drive him there like I do the cats.

Aargh, how frustrating.

Be sure you get a copy of the medical record from the dr visit and the vascular testing. The medical record will often give you more details, and it can come in handy if you need the ammunition.

Your fiance will probably have to do this himself because of the privacy regs. But the clinic or hospital cannot refuse to let him see the record; the law gives patients a right to see their medical record, obtain a copy and dispute any information that the patient believes is incorrect.

Good luck! The whole system sure sux, doesn't it?

Originally Posted by DragonLady

I would go to another doctor. There are other reason for the swelling, and there is medication for gout. Do not let him brush you off. I would go to the office and wait until I could talk to him face to face.

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I need to read more about that. He never mentioned any treatment. Also, from what I did read about gout, it is very painful even in the beginning. My fiancee had pain about 2 days AFTER the swelling began. It started around his ankle and then spread to his foot and all the way up his leg. Honestly, I don't think its gout anyway, but I'm not ruling it out. Gout is a form of arthritis (but not the kind of arthritis he has). It makes me wonder if its a ploy to turn the claim into a pre-existing condition.

Originally Posted by KittyCity

Aargh, how frustrating.

Be sure you get a copy of the medical record from the dr visit and the vascular testing. The medical record will often give you more details, and it can come in handy if you need the ammunition.

Your fiance will probably have to do this himself because of the privacy regs. But the clinic or hospital cannot refuse to let him see the record; the law gives patients a right to see their medical record, obtain a copy and dispute any information that the patient believes is incorrect.

Good luck! The whole system sure sux, doesn't it?

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Good advice. You're right. As soon as I get these documents in my hand I will be writing my dispute letter.

Well, Now I'm even angrier. The doctor's office still hasn't returned my call. Right now, if I were them, I wouldn't want to talk to me either. As soon as I can arrange a personal day, I guess I'll camp out in their office.

I've learned over the years that the best time to call is either over the noon hour or late in the afternoon. That's usually when there's a break in the schedule of seeing patients, doing hospital rounds, etc. and the docs are most likely to be tying up loose ends and returning phone calls. Mornings tend to be the worst times to call, cuz the docs are just so busy.

Hope you get your call soon.

Usually you don't need to see the doc to get a copy of the medical record. The business office or health information dept could probably just take care of this for you. When I needed a copy of a radiology report, I just called the main switchbord and told them what I wanted and they directed me to the right dept.

Hang in there!

I completely misread the thread title. I thought it said "Clam Died."

If he has gout, have him eat maraschino cherries. There is a substance in them that breaks up uric acid crystals, which is what causes the pain. They fall to the lowest point in the body, and even though they are tiny crystals, they have sharp points, causing pain.
Fish Oil and glucosamine supplements are supposed to be very good for joint health. My boss swears by them. She is 60 something, and gets around better than most of the young'uns that work for her.
Another thing that may help his pain is a massage stroke. Have him lie on his side and put a pillow between his knees to keep his spine straight. Take the heel of your hand and with moderate pressure (not enough to hurt, too much to tickle) rub in a small circular pattern over and around the hip joint. Biofreeze is a great product for joint and muscle pain, too. I hope he feels better, and that you get can all the bureaucratic nonsense taken care of.

I think it's just plain rude and unprofessional to not call you back. They are a doctor's office, not Wal-Mart. If I were not to return a phone call at work, I get read the riot act.

I'm sorry you are going through this. It just doesn't sound right. Because of privacy laws they will most likely not give you any information or release his medical records to you. Your fiancée needs to write a short letter to the doctor stating that he wants copies of all his medical records and sign and date it. If you need to get any x-rays, etc to bring to a different doctor, He needs to write the same kind of letter saying it is OK to release the films to you or whomever is going to pick them up. We recently had to do this with my father. Good Luck!!!

Originally Posted by KittyCity

I've learned over the years that the best time to call is either over the noon hour or late in the afternoon. That's usually when there's a break in the schedule of seeing patients, doing hospital rounds, etc. and the docs are most likely to be tying up loose ends and returning phone calls. Mornings tend to be the worst times to call, cuz the docs are just so busy.

Hope you get your call soon.

Usually you don't need to see the doc to get a copy of the medical record. The business office or health information dept could probably just take care of this for you. When I needed a copy of a radiology report, I just called the main switchbord and told them what I wanted and they directed me to the right dept.

Hang in there!

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I doubt I'll get to talk to the doc at all. Its a small office (2 doctors), and other than making an appointment, all you get when you call is an answering machine. There are options of who to talk to...nurse, office manager - but not even an option to leave the doctor a message! In the past I left a message for the nurse, which was returned 3 days later! This time I left a message for the office manager on Tuesday.

Originally Posted by AbbysMom

I'm sorry you are going through this. It just doesn't sound right. Because of privacy laws they will most likely not give you any information or release his medical records to you. Your fiancÃ[emoji]169[/emoji]e needs to write a short letter to the doctor stating that he wants copies of all his medical records and sign and date it. If you need to get any x-rays, etc to bring to a different doctor, He needs to write the same kind of letter saying it is OK to release the films to you or whomever is going to pick them up. We recently had to do this with my father. Good Luck!!!

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I decided that if I don't get a call back, I'll just take a vacation day Monday, go there and get the documents. My fiancee will need to take time off to go with me.

Originally Posted by SolarityBengals

I completely misread the thread title. I thought it said "Clam Died."

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Originally Posted by krazy kat2

If he has gout, have him eat maraschino cherries. There is a substance in them that breaks up uric acid crystals, which is what causes the pain. They fall to the lowest point in the body, and even though they are tiny crystals, they have sharp points, causing pain.
Fish Oil and glucosamine supplements are supposed to be very good for joint health. My boss swears by them. She is 60 something, and gets around better than most of the young'uns that work for her.
Another thing that may help his pain is a massage stroke. Have him lie on his side and put a pillow between his knees to keep his spine straight. Take the heel of your hand and with moderate pressure (not enough to hurt, too much to tickle) rub in a small circular pattern over and around the hip joint. Biofreeze is a great product for joint and muscle pain, too. I hope he feels better, and that you get can all the bureaucratic nonsense taken care of.

Click to expand...

Wow, I never heard of the cherry trick! Do you think it will work on other types of arthritis?
I bought Omega 3 fish oil and glucosamine, chondroitin, & MSM supplements for him last night!
The massage stroke sounds great too and I'll look for the biofreeze. Thank you very much! Do you work in the health field?

I am a massage therapist.
You can get Biofreeze at most chiropractors and day spas.

have the BF and you keep calling the insurance company and the doctors office, have the doctors office change there papers for the blood clot for the tests and have BF talk to his employer about the insurance,,,I think he was misled????? Have a better day, home soon: