Insurance Claim $1,500 rejected!! What can I do? Recourse?

[invisibraces]

I'm the primary insurer and I'm 27. My Aetna PPO Benefits insurance says 'Orthodontia coverage is available to employees, spouse and/or dependent children under age 26; Max $1,500 (PPO).' So my orthodontic assistant, my family/friends and myself took this as the under 26 age limit to only apply to dependent children. Fact is, the age limit applies to EVERYONE. I'm so upset. I already started treatment for 2 months when the ortho assistant called me to tell me that my insurance rejected the claim because of the age limit. I called my company HR who signed me up for Aetna PPO and they said there is nothing they can do.

Does anyone know if there is anything else I can do/try to opt out of paying this $1,500? This really sucks :(.

[Chicagogal]

Well, you can almost always appeal. Im not a huge fan of Aetna, but at least the appeals process might give you time to save up for this. You can partially hold them off by asking for an itemized rejection if they didn't give you one.

Otherwise, I really hate to say this, but the assumption of the age thing is on you. My policy said $3000 limit for dependents 19 and under with no details on any coverage for those older than 19. I called and they said they reject all claims for anyone over 19 (blah!). I did have the fortune of not starting treatment until I had all the facts (the ortho submitted it anyway and insurance shelled out for my records at least).

Because I was paying cash out of pocket my ortho gave me a generous interest-free payment plan. I'd definitely inquire with themon what they offer. If you can put some of it off until next year and have an Health Savings Account or Flexible Spending account you can see if it could come out of there in the future.

good luck!

[Skeptical]

Ugh, that stinks I feel for you, after 2mos I'm STILL trying to sort out the insurance coverage on my braces. Unfortunately, there's probably not a lot you can do with Aetna - even if the wording wasn't quite clear, they're probably not going to make an exception on an age restriction like that. I'd instead try to work with your ortho's office on giving you a discount/payment plan. If someone at their office, who should be knowledgeable about insurance plans & coverage, told you that your plan should cover you, as far as I'm concerned they're partially responsible and should cut you some sort of break.

Good luck and let us know how it turns out!

[peach]

That really doesn't make any sense. I have the same insurance and was 27 when I started treatment. I had called the insurance before seeing an orthodontist just to make sure it was covered for adults and I was told it was good to go. I'd appeal and see what comes of it. If they've changed the policy in the past 4 yrs then they need to reword their statement so that its clear that it won't cover anyone over the age of 26.

[BracedGeek]

I had insurance through my job that only covered dependents under 18. I bought some insurance that at covered 25% of orthodontia and also has low copays for regular dental work. There is no age limit, but they won't cover any orthodontic work that is already in progress.

[invisibraces]

[quote="peach"]That really doesn't make any sense. I have the same insurance and was 27 when I started treatment. I had called the insurance before seeing an orthodontist just to make sure it was covered for adults and I was told it was good to go. I'd appeal and see what comes of it. If they've changed the policy in the past 4 yrs then they need to reword their statement so that its clear that it won't cover anyone over the age of 26.[/quote]

Hey Peach, you had Aetna PPO as well? I guess they really did change the policy. I actually did call Aetna themselves today and they said that I'm not eligible so it's official :(.

I'm going to try to call the Ortho like you all said tomorrow to see if I can work out a deal with them. Hopefully they can give me some sort of discount.

In terms of Flexible Spending Account, how exactly does that work? Can I use it for ortho work already ongoing? I guess this may depend on my plan as well.

[Skeptical]

Invisibraces - if you have money left in your flexible spending account, you should be able to use it for your ortho - those policies are usually pretty...well...flexible As long as it's something medical/health related (which ortho is) I'd imagine you'd be good, regardless of where you are in the process. It's 100% your own contributions so it's not like an insurance company trying to avoid paying out their money.

Also, in response to Peach, not all plans are the same - the Aetna PPO one person gets through their employer can be slightly different from an Aetna PPO that you get through yours. Depends on what your employer negotiated and what's available in your region. I used to work for a health insurance broker and while I'm not an expert, I saw TONS of different plans during my employment and you can have a lot of variations of the same plan.

Between the orthodontist's office and your flexible spending, I hope you get some significant relief from that $1500 shortfall!

[Iam918]

I'm w/ Aetna PPO as well & my plan only covers $1500 up to age 18. I got stuck w/ the whole bill but w/e, eh?

As for the FSA, I'm going to sign up at the end of the year taking out w/e is left that I owe the Ortho in monthly payments from Jan '12 and on. As long as the Ortho bills you w/ a dated bill during the time you have the FSA active for you can use it to pay.

In other words, I started treatment now. All payments I'm making to them now are SoL for paying with FSA. However, once I sign up and it kicks in on Jan 1, 2012, I can pay the rest off w/ the FSA as long as the Ortho puts a billing date >01/01/12. I've already talked to the Ortho and they'll work w/ me on this so I can do this.
Make sense?

[Chicagogal]

I did something similar to Iam918.
my ortho gave me a bill that said "treatment balance" at the beginning of this year when my new FSA amount kicked in (ask your HR if it's an option, probably not available until your next open enrollment). I get a monthly bill dated for monthly dates this year (even though I started last year), that way it's always an eligible expense. The ortho wants to get paid so they should help you do it, neither of you wants a collection situation.

As for the appeal, the reason I mentioned an itemized rejection of the claim (if it just said orthodontia not covered) is that certain items can be appealed depending on what you're having done. Like I said, I was able to appeal the records at least and have them covered, that was $500 back in my pocket!

[Lisa43947]

I have Delta Dental and they cover adults for orthodontic work, up to $1000. I think they paid $500 the first year and $500 the next year. As you can see below, I've had braces for over 2 years.

[Iam918]

As for the appeal, the reason I mentioned an itemized rejection of the claim (if it just said orthodontia not covered) is that certain items can be appealed depending on what you're having done. Like I said, I was able to appeal the records at least and have them covered, that was $500 back in my pocket!

RE: appeals. I didn't even think to appeal mine as my ortho quoted a price of ~$5500 but stated he was giving me the Aetna "approved" (allowed?) price of ~$4500. So I figured w/ a $1k discount from the get go I was getting a good deal.