Here is a thread for that purpose.
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I crashed on my skis last year a developed delayed symptoms. I’d been through multiple PCP, ENT and PT visits, but my insurance denied the MRI saying I hadn’t had enough follow up yet. After a two week delay, I had a MRI at 6:45 PM. I received a call at 9:30 PM instructing me to go straight to the ER. I was admitted, had a neurosurgical consult that night, and a procedure (MMA embolization) to tread a 1”, midline shifting subdural hematoma the next morning.
As I was advocating for myself, explaining the potential underlying possibilities, I was told that they didn’t know why it was denied. They outsourced that function to a company I’ve never heard of and told me an appeal could take up to a month.
I’ve had care denied before for specious reasons. That along with the fact that we travel a lot, is the reason I’ll never electively choose Medicare “Advantage.” They don’t have this delay function.
For anyone who cares, it was BCBS.
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I’ve also had scans denied. I have/had cancer and my oncologist wants me to get regular scans. I’m supposed to get annual MRIs to make sure there’s no recurrence (which I have a pretty high chance of) and when I was first diagnosed, she wanted a PET scan to make sure it hadn’t spread further then was already known. Nope. Denied. No PET scan at all, and no MRI since initial diagnosis.
I know a type 1 diabetic who has been denied insulin, and a cancer patient whose chemo was denied by her insurance without notice so she walked into the clinic expecting an infusion and they were just like oops your insurance decided you don’t need anymore of that.
I recently had a colonoscopy. The procedure itself was covered as preventative care, but for some reason the anesthesia was denied even though this in network clinic requires the procedure to be done under anesthesia. They also denied the prep because I can’t do the liquid (I throw it up) so needed the pills. Nope, pills aren’t covered, just the liquid which is useless since I throw it up. Doesn’t matter.
Oh, and then there was the time D got scarlet fever of all things. She was so sick she couldn’t walk and I don’t drive so I literally carried her on my back and walked for 30 minutes to her pediatrician but ooops my insurer had suddenly canceled her coverage because of a clerical error (THEIR clerical error, by the way) and they forgot to mention that to me. Since we were unexpectedly denied coverage for the appointment, the pediatrician office sent us to the children’t hospital which was a 40 minutes bus ride away - my daughter was likely quite contagious at the time so we potentially exposed a bunch of people for no good reason since the insurance eventually admitted their error and reinstated her, but only AFTER all this.
And even what I have gotten covered has felt like a battle at times. And I have “good” insurance. It has just added so much stress to my life at times when I really needed to be focused on getting treatment and getting better.
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Yes, my S was having an endoscopy at a medical center because they had tried to perform it several times at a prominent medical center unsuccessfully. It was a BCBS participating & preferred med center and the MD in charge of the case was also participating & preferred. Unfortunately, turns out the pediatric anesthesiology group just left the BCBS network (due to low reimbursement), so it turned out they were out of network.
It took 2 years of fighting but eventually BCBS paid the fees. It wasn’t a pre-auth because unknown to me, there were NO participating & preferred pediatric anesthesiologists in all of Denver at that time!
Oh yeah, I have “good/great” insurance.
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My stupidest 9 month fight with BCBS was over RENTING a nebulizer to take my breathing medication. It had taken many months to locate the nebulizer in the 1st place and they wanted to rent it instead of buying it. I told insurer it’s very akin to renting an electric toothbrush in price but this machine could keep me out of the hospital. I’m sure all of us spent more than the $250 the blasted machine cost in time fighting that battle, which I also won.
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5 years later when I ordered a nebulizer from a different durable medical equipment company to replace the one TSA destroyed and refused to reimburse for, we had a fight for about 6-9 months over getting it reimbursed by insurer. The equipment company threatened to send me to collections but the claim had not been processed by insurer. Equipment company said to ignore the invoices they kept sending. We had a 3 way call between insurer, me and equipment company—still no resolution. Finally, I called insurer and asked if there was any form that MIGHT help fix this problem and MAGICALLY I was given the link to a form which I completed and had my MD sign and I sent to equipment company and FINALLY no more threats from equipment company (and no requests for me even to make a copay). It was a colossal waste of time and resources, again but the machine continues to work just fine. The amount in question was maybe $200 or so!
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My story isn’t dramatic or life-endangering, but I still get so mad thinking about it.
About 30 years ago, I had a small sebaceous cyst on my arm. The doctor I saw said that I had to have surgery to remove it. Full anesthesia, the whole bit. I never had one so I believed him. I went for a follow-up after the surgery in his office. I had to wait more than an hour to be seen. I was working full time and couldn’t spare being gone so long so I went to the front desk and started to make some noise. I was let into a room and waited even more. Finally, the surgeon came in, looks at the incision, said “Looks like it’s healing fine” and left. Seriously, that quick. Whatever.
I go to check out, and my paper work indicated this visit had been “moderately complex.” Laughable. I told the nurse that this was wrong, and she said that she couldn’t change it. I asked who could, because this is insurance fraud. She wasn’t terribly moved, so I started to raise my voice, loud enough so that the people in the waiting room could hear, and the doctor comes over and says “You have insurance, right? This won’t cost you any more no matter what is marked.” OMG, that was the wrong thing to say. (This was as HMOs were taking off, but I still had the good insurance). I told him that it wasn’t going to cost me more directly but that he spent less than 20 seconds with me so clearly this was not a “moderately complex” visit and to represent it as so was perpetrating a fraud on Aetna, which in the end costs all of us more. I said that loudly enough so that people in the waiting room could hear. He wanted to shut me up so they changed it.
This guy was the director of surgery at this facility. I learned that later. Months later, I was seeing another doctor, and he told me that I had another sebaceous cyst, this one on my neck. Good lord, I thought. I don’t want to have to go through all this again. When I asked him about setting up a surgery, he said “What? I’ll take care of it right now.” He gave me a local anesthetic and drained it right there. No going under or day surgery in a surgical center, etc.
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I still get mad thinking of the procedures they wanted to subject my very frail 93 year old mom with stage 4 cancer to. I asked whether their proposed procedures would make her more comfortable or aid in her treatment and reluctantly they said no and finally let her rest in relative peace. Yes, she had “good insurance,” but what about the hippocratic oath?!?! We had already declined aggressive treatments her cancer, so why not help us make her as comfortable as possible. Pointless uncomfortable medical procedures were NOT helping her comfort. S finally flew down from NYC to guard mom from people increasing her pain and helped her have as much comfort as possible the last weeks of her life. We had to have her geriatrician help us fight for better pain control. 
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One way reimbursements is making life extremely difficult for patients who need large amounts of supplemental oxygen is by making it nearly impossible to have liquid oxygen which is much more compact and portable than any other form. When I was 1st introduced to it in 2002 in Denver, it was the most common modality there and people had a reservoir like R2D2 in size that they used to fill & refill a special thermos that would provide them hours of O2. The equipment company would refill the reservoir every week or however often was needed. Patients could carry the thermos or wheel them in small carts, similar to tiny luggage carts.
Fast forward to the Medicare Competitive Bidding Program. Once the program was enacted liquid O2 largely disappeared in the US because it cost more to supply than other modalities. The last medical visit I had in Denver in 2016, I saw most patients hauling around entire shopping carts full of gaseous O2 tanks (similar to those used in scuba) so they could get through their medical visits.
At a medical conference I attended, a young working mother was nearly in tears taking about how she is only given enough “portable oxygen” to leave the house for 14 hours—per MONTH!
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I had an incredibly long and frustrating fight with United Healthcare over some jaw surgery. I’ll spare you all the the details, but they required dental models and x-rays for pre-approval which my surgeon sent. UHC claimed they were never received, twice!
After that I started picking up the records from my doc and sending them overnight. UHC still tried to claim the records were never received but when I said, “yes you did, they were signed for by John in receiving at 3pm two days ago” they suddenly found the records. This happened multiple times and they never once “received” the records without me calling them out.
They ultimately denied coverage so I paid out of pocket, around 20k. But since it was done in a hospital UHC paid some of the fees and also the anesthesiologist, so my cost was around 10k.
Well I filed an appeal (again with all the overnight mail and the claims they weren’t received) and they reduced their payment by 2k! I called to ask what was going on. I was allowed 3 appeals according to their policy, but I straight up asked, “If I file another appeal will your payment decrease again?” The response was, “It might.” And that was the end of the line for me.
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My husband had an endoscopy this past January that was pre approved. The hospital portion was approved and paid but the anesthesia and the surgeon were not.
I appealed but was denied. I should have pursued it more but I ended up paying because I wasn’t sure what to do.
This is not a denial but my experience trying to get healthcare insurance for 2025.
My husband retired with the benefit of retiree healthcare. This year the company decided to drop that benefit but pay us a stipend and we would have to find insurance on the marketplace. The company contracted with a broker to guide us through this process.
This has been a nightmare. As a qualified spouse, I also have a stipend. I think the company had two accounts, one for me and one for my husband. We needed those accounts merged.
I called 7 different times from November 1 and averaged 2 hours on the phone and hours every time waiting for the broker to call me back. Every time I thought my account would be fixed and we could choose our insurance. I needed to pick our plan by this weekend.
Yesterday it took me from 8 am sharp to 12:30 to I think make our selection. The stipend offered will be short of the price we need to pay. It doesn’t cover the medication my husband needs and doesn’t cover all of his doctors. It also doubles our deductible.
Thankfully my husband transitions to Medicare this year and his costs will go down.
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Type 1 diabetes is the disease that insurance companies dread the most. United in CA (Medical) had insulin pumps and CGM’s and related supplies as covered on their website. However they kept throwing up obstacles - it felt like they wanted to wear us down and they did. I filled a notebook with the various communications with different levels at United, conversations with doctors. Their required authorizations would change over time and we never seemed to meet them even with two different physician authorizations. These are medical devices that a person cannot wait for and I think they knew that. We ended up paying cash because my kid’s life was literally threatened by not having the supplies needed to have the devices function. Too much was going on in our lives to fight. I kept the notebook thinking I would do something about the situation but never did. I could not afford a lawyer at the time.
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I’ve had a few, but they were eventually paid.
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Hospital room admission for my kid 25 hours after ED visit. BCBS had a policy that the ED copay did not have to be paid if the patient was admitted 24 hours or less. When my kid went to the surgeon the day after the ED visit, that surgeon sent her straight to the hospital for admission and said the ED never should have released her the day before. Anthem paid for the ED copay!
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The anesthesiologist for my first C section was not a participating BCBS physician. It wasn’t like I had a choice, this was an emergency C section at 2 a.m. BCBS paid for that one too. Note…everyone else in that delivery room WAS a participating BCBS physician…
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Doctor in an emergency room was not a participating physician (hospital was)…like you get a choice there…you don’t! BCBS paid for that one too.
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That’s really horrible. These companies are truly parasitic and evil. And it sounds like you (and others on this thread) have the emotional/time/money resources to even fight back at all. The official policy of UHC and others seems to be to deny first, and then hope some people die and/or go away in the meantime.
I think one of the worst structural shifts has been the outsourcing of Rx benefits to, if it’s even possible, worse companies. One filled an epipen refill that was not requested (we had enough and I didn’t have refills “on” and we were waiting until the new FSA year). I didn’t have a cc on file and they used one on file for a different relative with the same name (!). Because the cc was an FSA debit card, that company wouldn’t reverse the charge. ExpressScripts claimed “you might have used some of the medicine” (an epipen, remember) so wouldn’t take the return. We were out over $500. There was later a lawsuit but it was too late to help us (re pricing of epipens and sneaky moves like this one). And that’s a “lucky” story because no one died or was injured!
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I just had a claim denied by Anthem/BCBS for a needed EKG, received after several years of no monitoring. My health insurance has been good/great in the past–before it acquired the “Anthem” label. The policy clearly says that all diagnostic tests are completely covered with no deductible. The latest thing I got from them after sending them a message about the “mistake” was a note that the claim had been sent back to the adjusting team. The interesting thing is that I expect they will eventually reimburse me. However, a child of mine took an ambulance ride that turned out to be out of network, and I fully expect that I’m out of pocket for that one. It will be 3K, even though the ride was about 2 miles, and nothing was needed for special care while the child was in the ambulance. I don’t see how there is any way for people to avoid these out-of-network ambulance charges, even if at the time, the patient thinks it is justified. How many people would ask an ambulance crew if they were in-network before riding in it? If you are calling an ambulance, you think it’s an emergency.
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My son has taken a powerful immunosuppressive drug for 21 years now, to treat a rare permanent disorder. The drug was originally denied as off label since the insurance did not know there were several forms. Our pediatric hospital had to intervene at high levels because “insured does not have the luxury of time to dispute the claim rejection” i.e., he was dying.
Yet just this year, he lost his job and thus his insurance, as of that day. This was 11 days before the administration of a new therapy, which is $16K every 8 weeks w/o insurance. His doctors scrambled to find a charity to help us; he and his wife scrambled to find ACA (Obamacare) coverage. But once they found it, the insurer made them go through a preapproval process EVEN THOUGH it was the SAME insurer (Cigna) and same drug they had approved on his work policy. This took almost a month, during which he had no medicine in his sytem (Cigna said that was fine, any hospitalization would be covered at usual rates)
His unemployment benefits did not cover ACA coverage and we get that. He has found a p/t job in his field, so now he can’t get unemployment anyway and it may disqualify them from ACA coverage at a rate that makes sense so his wife is being reclassified at her workplace. That’s a pay cut for her, but it comes with healthcare. These are both college grads with established careers and a safety net.
The “system” is archaic, punitive, immoral, impossible, and meant to benefit investors, not patients. As a country we should be ashamed.
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What always is a head scratcher for me is when the denials actually cost the insurance company more money. When my dad was put on the heart transplant list, his insurance company wanted him to wait for the organ in a hospital two states away vs at home with a visiting nurse and having the surgery in the approved in-network hospital less than 20 miles away. The doctors and I went on a letter writing campaign and finally got at home/local hospital approved but it was a battle. He was on the waiting list for a YEAR before he had his transplant.
Then we had to fight to not have expensive, invasive scans and procedures after he turned 80 but that was on the MDs, not the insurance company (but by then it was Medicare and VA benefits).
Personally I had an MRI denied after a shoulder injury and was told to do PT first. Did three months of PT and ended up with a huge rotator cuff tear because without the MRI, I was misdiagnosed with a labrum tear. My surgeon said that if I had the MRI first it would have likely been a much simpler repair (and a shorter recovery). (The orthopedic surgeon suggested going to a sports injury or ortho practice immediately after an injury and they know how to code properly to get the MRI approved).
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We have actually had good experiences with BC/BS including Anthem for my kid and now Medicare Advantage for me.
We live in fear of any period without health insurance. My now 30 something kid has friends without health insurance. When my kid left a job, the employer made a mistake and long story, I paid $2k for a two week lapse because thee ACA plan didn’t take effect unless you applied mid-month. My kid also cannot go abroad for long despite opportunities in their field, because none of the insurance companies like Geo Blue will cover their type 1.
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I’m a doctor who treats an expensive, sometimes life-threatening, mental health illness. We have 5 clinics spread over our large sprawling metro area. UHC covers care in only one clinic. So families drive up to 90 minutes each way fighting traffic, kids missing school, when there is an identical clinic minutes from their home. Same w inpatient care–they cover 2 facilities ~6 hours away in adjoining states, but not the local facility despite excellent outcomes. It’s to discourage care.
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