Woman initially denied reimbursement for covered procedure gets refund

Posted at 10:24 PM, May 17, 2015
and last updated 2015-05-17 22:24:39-04

LOWELL, Mich. -- After Connie Krueger sought help from FOX 17 Problem Solvers, she is being reimbursed by her medical insurance company.

Connie had agonizing mouth pain due to gum disease and needed a costly procedure to treat the problem. “November 13 of 2013, I had all of my teeth extracted," Krueger recalled.

She said it cost "a little under $10,000.” Fortunately, her husband had paid Blue Care Network of Michigan more than $300 each month for several years.

“I called Blue Care Network before the procedure, before November 13, and asked if this procedure was covered under medical," she said. "I was told by them that it was."

After a successful surgery, she said her dental plan kicked in about $900. Supplemental insurance chipped in another $3,400 or so. Her husband paid $5,300 out of pocket, of which she said Blue Care would reimburse them $3,000. So she mailed the reimbursement form.

“[I] never heard a thing from them. I called them, and they said they couldn’t find it. So then I faxed and mailed a second copy. Then they got that. Then after that, they sent me a letter in the mail saying I was denied.”

Connie said every time she called, she got a different reason her claim had been denied.

“One of the reasons was it wasn’t performed by a Blue Care Network approved surgeon, or it wasn’t in a Blue Care Network approved facility. I didn’t have the … it wasn’t the right codes for billing. I needed a referral from my doctor," Connie said the reasons for denial went on and on.

Her doctor even wrote a letter telling the health insurance company the procedure was medically necessary.

“I keep getting the runaround now, and I called just a few days ago. I finally, I said, 'I want to talk to the CEO of the company or someone higher up.' Oh, they laughed at me," she said.

“What is the sense of having insurance and paying all those premiums if you can’t use it? You know, I just don’t think that they should get away with not paying.”

So she reached out to the FOX 17 Problem Solvers for help. The Problem Solvers called the company and a spokesperson put Connie in touch with the grievance coordinator. In the meantime, the Problem Solvers were told Krueger wasn’t covered because her policy didn’t cover gum disease.

However, two months after Krueger's interview with the Problem Solvers, Blue Care Network had a sudden change of heart. Connie was told an employee found an important call record.

“Yesterday, I got a check in the mail for $2,965," Connie said. "So, I’m very happy about this."

"It was kind of ironic that the day before that, I called them and said that this segment was going to be aired, and I think you emailed them too," she said.

"The next day, they miraculously found my records of my phone call that I made to them before the oral surgery saying they would approve to pay. Before that, they couldn’t find any records. They said there was no such call. Or if there is a record, [BCN said] I was misinformed.”

She's glad she reached out to the FOX 17 Problem Solvers.

“Couldn’t have done it without you guys. I know that the Problem Solvers, if they weren’t involved [Blue Care] probably would still be denying it."

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