If an insurance company is allowed to stall the progress of an appeal for months through gross misrepresentation and incompetence, should they then be allowed to deny a claim for having maxed the prior year's benefits while the appeal was ongoing?
Value Options and Great West just did that and I am not sure why the government keeps giving these guys contracts, nor do I want to speculate on that. They initially denied a claim out-of-network and would not authorize the care despite the fact that they had no in-network facility within 80 miles. Appearing to have won the initial appeal, the claim was then stated to have been "pended" for a contract set-up problem. This was followed by: a billing issue; a dispute over which company was responsible to pay; and two months later denied as the patient had maxed their benefits a month after the treatment at our facility seven months earlier. We are still fighting this but one lesson learned is...
When appealing a claim, particularly one with a known day or dollar max, demand that the proceeds at issue be legally "pended" until all appeals and legal options have been exhausted.
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