Help with drafting a letter to health ins co

[Buda]

We have private health insurance through DH's job and in Sept I went to the doc here as I seemed to be losing a lot of hair, Questions on here and internet research had immediately suggested anemia or thyroid problems. Doc suggested I saw dermatoligist at same clinic which I duly did. Lots of blood tests and 2 urine tests and a gynae exam later it was discovered that I had a UTI and that could be the cause of the hair loss. Had a ten day course of anitbs which sorted it all out.

Insurance company refused to pay as "hair loss is not covered".

I paid the clinic direct but now want to write to the insurance co and get them to reconsider in view of the fact that the cause was obv clinical. If my bald DH had gone with male pattern baldness I would understand but I feel a blanket "hair loss is not covered" response is not fair. Esp as it is common for both anemia and thyroid and inflammation issues to cause hair loss.

Problem with my letters is that I waffle and get all emotive which is not good! Any suggestions for wording would be appreciated!!

Thanks

The hair loss was a symptom not the illness you were treated for. They are covering you for treating the illness. Try that?

OK CMOC - will try that - thanks.

OK - draft letter below - any thoughts??

Please find enclosed receipts relating to tests carried out to discover the reason for the hair loss I was experiencing. The direct claim from XXX Medical Centre on my behalf was refused on the basis that ?hair loss is not covered?.

Whilst I understand that treatments for male pattern baldness etc would not be covered I feel that certain cases are different and that clearly the hair loss had a clinical reason. From what the doctor told me hair loss can be caused by inflammation anywhere in the body. Obviously other reasons for hair loss can be anemia or thyroid problems.

I would ask you to reconsider this claim in view of the fact that the hair loss was obviously a symptom of a clinical disorder.

Many thanks and I look forward to hearing from you.

How about saying something like:

Please find enclosed the reciepts from XXX medical centre relating to an episode of investigation and treatment which resulted in the diagnosis and treatment of a urinary tract infection. I am surprised that you have initially declined this claim on the basis that one of my symptoms was hair loss, and that "hair loss is not covered"

Thank you for your reconsideration of this matter, and I look forward to hearing from you.

Takes the focus away from the hair loss a bit?

I understand what you are saying lpp but the clinic put the claim in once under the original hair loss and once again with hair loss and lethargy and it was still refused. I want them to acknowledge that they can't just blanket refuse hair loss when it CAN be clinical.

It sounds like the Clinic have classed the treatment as being for the hairloss not the UTI. Can you speak to them and get them to resubmit it as a claim for the UTI? If they are saying their costs are for the hairloss you have a problem. I would talk to them.

Would the clinic resubmit the claim and give the UTI diagnosis rather than the symptoms that you presented with?

Sounds like the insurance company have just shut their ears as soon as they heard "hair loss"

Anyway, i think that your letter is fine. Maybe you could put in a bit about the lethergy and any other symptoms that you had so that they know that it was not just an isolated symptom?

Good luck!

Well I did go into the clinic sort of all guns blazing when I discovered the claim had been denied. I know the doctor pretty well and she did write another letter and submitted that saying it wasn't just hair loss and they still refused it. I

Did you do a claim form? What did you put as the condition on the c/f - more importantly, who completed the medical section and what did they put as the condition? (I spent 9 years as a claims assessor for a PMI! Who are you insured with?) If everything related to the claim says hair loss I think the very most you can expect to get refunded is the blood & urine tests - and then probably only if you can get the gynae to put in writing that these tests were for suspected UTI. If what you have sent them is something from the doctor (GP or consultant?) saying the UTI "could be the cause of the hair loss" I think you are unlikely to get anything back TBH!

Oh hi Drusilla - insurance is with Allianz.

All I want refunded is the blood and urine tests. The antibs were cheap so I didn't bother claiming for them. I was given a solution to use on my scalp - again cheap and I didn't claim.

The dermatologist filled out the claim form I thing and I now know that I should have just seen the GP as I think it is the fact that the GP referred me to the dermatologist that is causing the problem. They are in the same clinic and it was just easier for her.

I think if the dermo filled in the c/f and asked for the blood and urine tests you will have a hard job getting them to pay for this. To pay for tx for a uti they would expect the c/f to be completed by a gynae. I worked for AXA, so am not an expert on Alianz! But everything you have said would have screamed at us that this was someone trying to claim for something not covered, I'm afraid. Have you got a consultation bill from a gynae? You need something to show that you saw a gynae for ?uti and that the gynae and not the dermo ordered the tests. Failing that, if it is corporate cover, you could ask your DH company to intervene for you! Some of our companies would do that for their staff, but not all. I would also say never have any private tx if you need the ins co to pay for it without getting some sort of pre-auth from them!

HI again Drusilla - I understand what you are saying but I feel it is very unfair to just blanket refuse to cover ANYTHING to do with hair loss when it was patently due to a clinical cause. The GP I saw referred me to the dermatologist as (in her words) "I would rather deal with a heart attack" - and therein lies my problem.

Am a bit annoyed (to say the least) as we discussed possible reasons and she even said prob anemia or thyroid. I don't feel I am trying to claim for anything that I shouldn't be entitled to - the sheer fact that the hair loss stopped after the antibs for the UTI sort of says it all doesn't it?

I did see the gynae in fact. The dermatologist said I should to rule out any gynae type infection. The results of my second urine test were back that day and I discussed the whole thing with him and he was the one who prescribed the antibiotics.

We don't tend to need pre auth for tx generally - we are overseas and they only require pre auth for major stuff really.

I am totally pissed off with GP now as if she had just requested tests I wouldn't be in the position.

And believe you me I will be involving DH's firm if this not sorted! I can be like a dog with a bone!

I know it seems unfair - I'm just trying to show you how the ins co will see it! They will see a dermatologist saying these tests were investigations for hair loss. If I were you I would get the derma to write to them saying actually these were investigations into symptons of thyroid problem or involve DHs employer! We used to pay quite a few claims "ex-gratia" when the employer got involved