I just received a call last night saying they would consider the fusion surgery for payment. Now they say they will not cover it due to being done out of the country. After this the advocate sayis you can appeal the decision, I asked if there was any use, I cannot change the fact that it was done out of the country. I did however ask why when I called Cigna many times in regard to this both before and after surgery they did not tell that anything done outside of the U.S. is not covered. She could not answer that question, then I explained I also read the policy and I did not see any mention that of this fact. I explained that I was told from Cigna it would be considered out-of-network which I could understand. I then explained after I returned from Austria, had the invoices I called them again making sure the invoices were written exactly like they needed with all the information. As a matter of fact they were not and I had to contact the billing department to have them redone to be exactly as Cigna needed.
So I asked her again why after all this no one ever told me this fact? why is it not in the benefit book? You would think that this is a very important non payment issue people should know about.
She said I brought up very valid questions and should start the appeal process.
First they would not pay because it was artifical disc, then when I explained this was for the fusion (which we all know is a covered surgery), then it is rejected due to the fact it was done out of the country.
Sounds to me they are just looking for reasons not to cover this and I think will give the appeal process a try. I also found someone in the State of CT office that said she would be happy to try to help. Would you handle this yourself?
What do you think?
Any suggestions on how you would handle this?

Thank you,

Judy

Judy, this is really rotten news. Senseless. If you want company on the picket line, I'll join you one day downtown. I hope you found some support at State CT Insurance Dept. because this sounds like a policy lingo that is in their ball park and I'd bet they can dispose of this with one phone call. Years ago when Allstate would not pay after I won the court decision, they made the call and I got paid. Last year TIC denied my friend a homeowner's claim that was just about as blatant robbery as Cigna to you and the Insurance Dept made a phone inquiry and he was paid. I have to say from my experience, they are a state agency doing it as right as humanly possible.

I would start the appeal process tho it will likely be denied so you might consider engaging the expertise of an attorney to see if there's a better chance of having the surgery paid for since there's no statement in writing that you can find that wouldn't treat this as an out of network provider.
There may be loopholes the HMO can utilize such as the PCP makes referrals to the Specialists and if the specialists here in the states are recommending fusion and that's standard practice in the community for this type of condition you went against advice given and acted independantly seeking other treatment.
I don't know if this would be a valid arguement or not but after working for HMO/Managed Care for 12 years I have seen quite a few things that seemingly should have been covered get denied repeatedly..
Persistance *tenacity* might help in your case~