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Need wording help for grievance

Need wording help for grievance

Postby readyandwaiting » Thu Dec 11, 2008 8:33 am

Someone here gave me a great way to word a grievance case and I need help again but can't remember who. After explaining infection and such I did get approved and had surgery. Now I am getting bills left and right because my insurance company is saying that I have a 50% copay. They claim I was told this in May of this year. My surgery was denied in August and then I won the grievance in September and just had the surgery in October.
Can anyone think of a way to word that it would not work on a timeline that I was told I have to pay 50% 3 months before I was denied and 4 months before I got the call that I was approved?
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Postby swrong » Thu Dec 11, 2008 11:06 am

I'm sorry, I cannot help you with the wording, no good at that, but, if someone gave you good advice in a post, you might want to try a search (towards the top of the page in the orange) and put grievance and your name (ID) in the author section. You might want to also just search for grievance and see what other posts say for ideas. Hope this helps.
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Postby NewBelly08 » Thu Dec 11, 2008 1:25 pm

bump
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Postby True » Thu Dec 11, 2008 2:21 pm

man, you know, I always prefer straight to the point. I know it's always better to approach with some measure of respect--you're more likely to be treated likewise--but it appears they are really just dicking you around. I would really just go for the balls and give them a what-for. Good luck. I hope you win your case.
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Postby ronda44 » Thu Dec 11, 2008 8:57 pm

LOL.... Since in my career field... I do WRITE ALOT OF STATEMENTS... Keep in mind that I do love spell check and so you might not want to use my spelling...LMAO
I would want to use words sort of along these lines....:
Due to it appearing to be a obvious attempt to confuse me into paying the 50% of my COVERED CLAIMS, I am grieving the demand that I pay these charges. I have kept very accurate documentation on every date that there has been any communications between myself and(the insurance company). The timeline of my Surgery and any charges associated with this surgery is not at all consistant with your attempts to lead me to think that I was informed of the 50% co-pay. You are alledging that I was informed of this in MAY, but yet my first submission for approval was indeed DENIED in AUGUST. So,THREE MONTHS after you are claiming that I was informed...? My surgery approval was DENIED. After my surgery was indeed approved by (insurance company) in Sept., I then underwent surgery in October. The timeline here is completely inconsistant. I fI had indeed been informed on the 50% co-pay,(which I know that I was NOT). Wouldn't that information been given upon your APPROVAL of my Surgery? Not THREE MONTHS BEFORE YOU DENIED COVERAGE for my surgery? This appears to be a obvious "attempt" to confuse me, which since I did take very detailed notes as far as my researching my surgery as well as any paperwork that had to be submitted and any papperwork that I recieved from (insurance company)as well as any telephone conversations. The attempts to confuse me to the point of submission into paying this 50% co-pay is baseless, as I was NOT INFORMED of the 50% co-pay. To keep this simple I will just state "FACTS"(which appears to not be a common practice with (insurance co. name). I was DENIED coverage on my surgery in "AUGUST", after re-submission for approval, I was approved to have my surery in "SEPT", my SURGERY WAS NOT PERFORMED UNTIL "OCTOBER". How would the month of "MAY" come into this case at all? Why would I have been informed in "MAY" about a 50% co-pay when you denied coverage on my surgery in "AUGUST"? The complete inconsistancy should speak for itself in this matter.
O.K. I know it is a really rough draft of somethin'... but... if you need any more advice on any other subject with this insurance company, please let me know. I know that my stuff has to be factual and pretty much straight to the point. I hope this helps, it may not... but... maybe we can help u come up with whatever you do need! :D
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