Problems with BUPA Claim Denial

[patekatek]

My wife had surgery in Dec. 2013 to remove a cyst and ovary. In mid-March we received a letter from BUPA denying compensation for the surgery based on a pre existing condition. We asked for their proof as we have no knowledge of any such condition. The paperwork that they are using for denial is from a hospital in Chonburi. We contacted the hospital, obtained the same medical records they provided BUPA, then had these records researched by the doctors in Chonburi as well as by some people specializing in medical claims. No person can find any notation of a pre-existing condition.

When we sent an email and made phone calls to BUPA they said they would review it again. Today we got a letter from them claiming a pre-existing condition and they refuse to cover their obligation.

We have an insurance company that is simply refusing to pay a claim they are obligated to pay. What can we do? Is there a creditable organization that can put pressure on BUPA to prove without a shadow of doubt that a medical condition existed before the surgery? Everything BUPA provides us shows no proof.

Regards,

don

[lopburi3]

Don't they have a published procedure to follow? Normally the review procedures are a part of your insurance policy. It likely is also dependent on the country the insurance is issued from.

[patekatek]

Well, about 1/2 hour ago BUPA emailed my wife a copy of a medical record from Chonburi that we have never seen. This record appears to support BUPA in their pre-existing condition claim denial. We now have to refocus our efforts on the hospital that had this record and did not disclose it to us nor discuss the medical issue with my wife. It seems that I am S.O.L. and will have to eat the $5,500 expense for her surgery.

[lopburi3]

Sorry for the expense but happy you have found out the issue - expect it was not the direct object of attention so not discussed with patient - which seems to be quite common.

[ghworker2010]

Well, about 1/2 hour ago BUPA emailed my wife a copy of a medical record from Chonburi that we have never seen. This record appears to support BUPA in their pre-existing condition claim denial. We now have to refocus our efforts on the hospital that had this record and did not disclose it to us nor discuss the medical issue with my wife. It seems that I am S.O.L. and will have to eat the $5,500 expense for her surgery.

What is SOL?

[JoePai]

Google = "S**t Outta Luck"