Goodhealth Scam..

[Topprofile]

Be careful about Goodhealth and BNH. They might in bed together..

I visited BNH as I had a soar throat (really bad) and the Doctor recommended that I should remove the tonsills because if the infection would come back it could spread to the heart (Reumatic fever) and the kidneys.

Of course you listen to the doctor and as I was insured by GoodHealth I didn't think anything more about it. I even contacted Goodhealth in advance who emailed me some documents for the doctor to sign and send back to them.

After surgery I sent all documents to GoodHealth who now refuses to pay for the surgery stating that I knew I had this problem before signing up for the insurance. The Doctor apparently told them that my "problem" started earlier (before I signed up). But I have never visited BNH before my first visit when the doctor recommende removal of the tonsills.

Accoding to Goodhealt I am not covered. A Pre-existing Condition is "Any Medical Condition or Related Condition for which You have received Treatment, had symptoms of, to the best of Your knowledge existed or You sought Advise for prior to Your Date of Entry..."

Sure I have a had a soar throat before, who hasn't?? Especially if you live in Bangkok.

This means that if you ever had a soar throat before and you need to remove your tonsils (on recomendation from the doctor) you will not be covered.

I wonder what they say about having a headache and then later next year I find out I have a braintumour.. Will the headache be regarded as a Pre-existing or Related Condition??

Since I pointed this out, Goodhealt has stopped replying to me.

Can anyone tell me what to do?

Thanks

[h90]

Be careful about Goodhealth and BNH. They might in bed together..

I visited BNH as I had a soar throat (really bad) and the Doctor recommended that I should remove the tonsills because if the infection would come back it could spread to the heart (Reumatic fever) and the kidneys.

Of course you listen to the doctor and as I was insured by GoodHealth I didn't think anything more about it. I even contacted Goodhealth in advance who emailed me some documents for the doctor to sign and send back to them.

After surgery I sent all documents to GoodHealth who now refuses to pay for the surgery stating that I knew I had this problem before signing up for the insurance. The Doctor apparently told them that my "problem" started earlier (before I signed up). But I have never visited BNH before my first visit when the doctor recommende removal of the tonsills.

Accoding to Goodhealt I am not covered. A Pre-existing Condition is "Any Medical Condition or Related Condition for which You have received Treatment, had symptoms of, to the best of Your knowledge existed or You sought Advise for prior to Your Date of Entry..."

Sure I have a had a soar throat before, who hasn't?? Especially if you live in Bangkok.

This means that if you ever had a soar throat before and you need to remove your tonsils (on recomendation from the doctor) you will not be covered.

I wonder what they say about having a headache and then later next year I find out I have a braintumour.. Will the headache be regarded as a Pre-existing or Related Condition??

Since I pointed this out, Goodhealt has stopped replying to me.

Can anyone tell me what to do?

Thanks

I would also question if it was really necessary to remove the tonsils. I think 90 % of all the removes are only be done to finance the docs new BMW.

Anyway I'll keep that in mind before I go to hospital next time.

As for Goodhealt in such cases it works in Europe to tell the sales guy that you'll cancel the contract with them, but I have my doubts if it works in Thailand....

[Topprofile]

Sure, but if your doctor tells you that you can get problem with your heart (and as I'm no doctor) I don't want to take any chances.. Would you?

Of course it's a way of making money (see my other recent post about BNH), but why am I not covered? Can the insurance company just do whatever they feel like...

I can probably call my creditcard company and get my money back for the goodhealt signup but..

Fee for surgery minus sign-up fee for insurance..

Well the difference is about 50.000thb...

Goodhealth is registered in HongKong and not sure what I can do here..

[h90]

Sure, but if your doctor tells you that you can get problem with your heart (and as I'm no doctor) I don't want to take any chances.. Would you?

Of course it's a way of making money (see my other recent post about BNH), but why am I not covered? Can the insurance company just do whatever they feel like...

I can probably call my creditcard company and get my money back for the goodhealt signup but..

Fee for surgery minus sign-up fee for insurance..

Well the difference is about 50.000thb...

Goodhealth is registered in HongKong and not sure what I can do here..

short question how much was it to remove the tonsils?

[Topprofile]

In BNH about 75.000thb

[Sheryl]

The condition the doctor was referring to must have been streptococcal tonsillitis and while it is true that this can cause rheumatic fever it is also true that this complication can usually be avoided by simple antibiotic treatnment unless the tonsillitis proves chronic. Anyway that's the least of your problems now.

Unless you had this same streptococcal infection before you signed on for the insurance -- which I very much doubt -- this is in no way a pre-existing condition. That you may have had throat infections, streptococcal or otherwise (and how would the doc know that anyhow?) in the past makes no difference. Strep throat infections are common, they go away and can newly occur.

It sounds like somewhere in the medical documents the doctor wrote that you had chronic tonsillitis, which doesn't square with the history you give in your post. Plus it is very odd that it wasn't mentioned on the forms he signed befiore the surgery (or if it was, vey odd that the company didn't say something then).

It may require phone calls to Hong Kong but I think you should fight this. All health insurance companies have an ombudsman type person to handle dusputes, call and insist on talking to that person. Tell them that you were NEVER diagnosed with tonsillitis before, the symptoms started only X days before the surgery, point out that they were notified ahead of time and made no objection, and generally raise hel_l, threaten to sue, write to the HK newspapers etc etc. You can also demand your hospital records from BNH to see if the doctor wrote anything about the condition being chronic or not. By law, Thai hospitals have to release patient records on request. And if you find that the doc did misrecord your history, you can complain to the hospital and demand that they correct the record and notify the insurance company. (for that, I'd suggest to start with a face-saving "language problem caused a misunderstanding"approach first, can swtich to hardball later if necessary)

Edited July 5, 2006 by Sheryl

[Topprofile]

Sheryl - Thank you for your info! Really appreciate it!

Do you happen to know where I can contact the ombudsman? That should be a government agency or similar I guess in that country?

Thanks again!

Rob

[h90]

In BNH about 75.000thb

normaly it is not a big deal, why that expensive?

[Sheryl]

Sheryl - Thank you for your info! Really appreciate it!

Do you happen to know where I can contact the ombudsman? That should be a government agency or similar I guess in that country?

Thanks again!

Rob

No the obudsman should me on staff at the Insurance Company tself. Although there will also be some sort fo governmegt agecy that reglates/license insurance companies, I don't know what that is for HK but perhaps some other readers can advice.

Meanwhile as a first step I suggest you get your records from BNH. If you find that the records state "chronic tonsillitis"or otherwise record the onset as long ago, go to the hospital (Director of Director of International Reations Dept) with that in hand and explain that it is incorrect and has resulted in your insuranceclaim being denied and request that it be corrected and the insurance company so notified.

If the records say nothing of the sort then you have proof in hand with which to pursue your insurance claim.

One possibility for how all this happened -- it is not really standard practice (and hence many insurance companies would not agree to pay) to do a tonsillectomy for a single episode of acute tonsillitis. Knowing this, the doctor may have intentionally described it (at least to the insurance company) as chronic tonsillitis, since for that surgery is indicated. He may have done this either because he wanted to do the surgery for his own (profit) reasons or because he really thought it would be best for you and was trying to help you get it covered by insurance. Presumably he didn't know how long you'd had the insurance? In which case in an effort to justify insurance coverage for a surgical treatment he may have deliberately misrecorded the duration of your illness with the intention of getting the company to pay only it misfired.

As you are going to need to call HK hope you have a cheap long distance program? There are several accessible from Thailand. I use Global which you can apply for online.

[Farma]

In BNH about 75.000thb

That is expensive I had laser snoring treatment in Bangkok. They took my tonsils out at the same time. It cost 20,000 B all up.

[Topprofile]

Sheryl - Thanks again! I will go to the hospital on Friday and ask for all records.

I sent the claims department an email yesterday evening saying that I have never been dignosed with chronic streptococcal tonsillitis and that this was in no way a pre-existing condition (as they claim). I told them if they will not solve this I will ask my lawyer to contact their ombudsman.

I got a reply back within 30 minutes saying that a manager would contact me... we'll see what happens.

The first quotation I got was an estimate cost iof 2,650 USD. But I managed to get it down... Well I guess that's what you get for going to Privatised Hotel Styled hospitals..

[h90]

Sheryl - Thanks again! I will go to the hospital on Friday and ask for all records.

I sent the claims department an email yesterday evening saying that I have never been dignosed with chronic streptococcal tonsillitis and that this was in no way a pre-existing condition (as they claim). I told them if they will not solve this I will ask my lawyer to contact their ombudsman.

I got a reply back within 30 minutes saying that a manager would contact me... we'll see what happens.

The first quotation I got was an estimate cost iof 2,650 USD. But I managed to get it down... Well I guess that's what you get for going to Privatised Hotel Styled hospitals..

I read from an apendix remove (spelling right???) and it was 7.500 Baht.

A friend of mine had the tonsiles removed and it was arround 30 min and after 2 hours he went home. Do we really speak from the same thing, that can not cost 75.000 Baht, that is more in the 5000 Baht range.

[Topprofile]

The price of 75.000thb was in BNH Hospital. Send them an email and ask for a quotation and you'll see what they reply.

I had the tonsills removed and stayed over night. Price for room about 8000thb per night, the rest I guess is money for the Doctor's new house and new Mercedes 600 (and some for the shareholders)

[kat]

Yeah, I think Sheryl gives good advice here. I would've preferred if you went and asked for your hopitial records before contacting the head office. But, I definitely think you should challenge this blatant rip off scheme.

I think my latest suspicions about BNH have been confirmed. I had the same feeling there a few months ago - I appeared to be the dental surgeon's new condo rather than a patient.

Forget BNH and their free cappucinos.

[egeefay]

I am not surprised that your insurance company denied your claim.

Heath insurance companies thrive on people who pay premiums but make no claims.

That's their ideal customer.

You are obviously not since you broke your agreement with the insurance company by trying to make a claim.

[backflip]

The OP has a couple threads open, regarding BNH. If he has had so many problems, as described in detail, why does he keep going to BNH? There are other hospitals in Bangkok...

[Topprofile]

The OP has a couple threads open, regarding BNH. If he has had so many problems, as described in detail, why does he keep going to BNH? There are other hospitals in Bangkok...

What is OP?

Thanks

Edited July 11, 2006 by Topprofile

[Tywais]

The OP has a couple threads open, regarding BNH. If he has had so many problems, as described in detail, why does he keep going to BNH? There are other hospitals in Bangkok...

What is OP?

Thanks

Original Poster

[Topprofile]

HAHA I see...

Well if Backflip cared to read the stories he would see that there are 1 issue for BNH and 1 issue for Goodhealth..

1 issue is for me personally and 1 is for my nephew.

Total of 2 posts... Sorry to flood your private forum..

Read before you post some incorrect statements.

But I guess you are working for BNH or just doesn't have anything constructive to add..

If you don't have anything to say why do you care reading this post or posting in this thread?

Edited July 11, 2006 by Topprofile

[cigar7]

I have worked for health and life insurance companies (IC) in Canada for numerous years. Be very careful when dealing with them, they will try to find reasons for not paying claims.

When the IC indicates something, always ask for a copy of the statement or fact. In your case, ask for a copy of the Doctor's statement. Examine the statement carefully to ensure the IC has not jumped to a conclusion based on vague wording by the Dr. Next, make an appointment with the DR. and confirm the statement. Next, ask the doctor for facts to substantiate his statement, like blood test results, lab results, etc. Be sure all documents are dated. The bill from the hospital must be itemized and dated. Every swab, test, injection drug, etc. should be recorded on the bill. Next, examine all evidence and timelines first by yourself, then with the Dr. and see if both of you reach same logical conclusion, in your case an existing condition prior to policy start date. Research your alleged prior condition on the internet, become a mini-expert. Find out about the incubation period, etc.. Also ask questions like "what alternative" conclusion could have been reached or treatment could have been provided?

Now to really find a scam, more information and profiling is needed. For example, Dr. X may be a statistical anomaly. There are 2 major directions to take: unnecessary medical procedures and secondly overcharging. Did he explain to you the alternative treatments available? Rarely is there only one way to deal with a problem. You should ask him "how many similar operations have you performed in the past year or two?" What was the average price/cost of each? How have your peers performed with the same indications as he saw in you? I use to have a massive data warehouse of this type of info, and it became quite easy to find the anomalies. You have to be very tactful when asking the questions. If the questions were asked by an insurance company rep., the DR. may ask you to talk to his lawyer. Also, you may want to check with the medical governing body, about any complaints about Dr. X. After gather all of the evidence, discussing it with the Dr., IC and or the hospital, if you feel you have been dealt with unfairly, file a complaint with the governing body.

Please provide us with the Doctor's name!

[cigar7]

In the future, I recommend you consider the following:

When dealing with a non-emergency situation, ask the Dr. to submit pre-determination (PD) claim to the IC, and ask the IC for their PD statement. The PD should tell you how much the IC will pay, if anything. You'll learn about co-pays, maximums, and other eligibility requirements and limitations. I have never heard of an IC not honouring their PD.

In your case, the claim form should have revealed the the DR's pre-existing problem conclusion. The claim form should have asked the question.

[Topprofile]

Well it seems as if you have to be a lawyer before you start dealing with insurance companies and a doctor before you go see one.

I plan to go see the doctor again during this or next week to try to determine where this has gone wrong.

Thanks alot for the input! I have learned a lesson and will in the future be more aware and question everything.

[Sheryl]

If I understand the details of the original post correctly, he DID submit a PD and it was approved.

The procedure was a tonsillectomy so incubation periods etc don't apply. Actaully tonsillectomy is not indicated for a single episode of acute tonsillitis (which seems to have been what he had if indeed he had tonsillitis at all), only for chronic tonsillitis. And of course if it were chronic then the question of when it started relative to when his policy took effect arises. What puzzles me is why that issue was not raised at the PD stage. If the PD forms said acute tonsillitis I would have expected the IC to deny the procedure and if it said chronic I would have expected them to explore the issue of time of onset then, not approve it and later deny the payment.

Anyhow he needs to find out:

- what information was initially provided to the IC re diagnosis and onset

- same on later documentation to the IC

-and what it actually says in his hospital records

And yes, one should always get at least one second opinion on non-emergency surgery...and be especially aware of procdures that are often done unnecessarily e.g. tonsillectomy (usually unnecessary unless there is a history of recurrent tonsillitis) , appendectomy (necessary enough if one really has appendicitis but that diagnosis is sometimes made on flimsy grounds), hysterectomy (unless for cancer or a medical condition that did not respond to more conservative therapy first) and "exploratory" anything. The last was more justifiable in the pre-scan and ultrasound days but with proper diagnostics these days is very rarely appropriate.

I have often thought that if I hadn't become a nurse for other reasons it would still have been well worth it just to be able to defend myself, friends & famly from incompetence and intentional malfeasance. ..

[Sheryl]

I have worked for health and life insurance companies (IC) in Canada for numerous years. Be very careful when dealing with them, they will try to find reasons for not paying claims.

Don't know about Canada but in the US they do a whole lot worse than that. They actively interfere with your medical care and threaten your doctor directly without your knowledge. HMOs are already well known to require their doctors to follow limitations on treatments and diagnostics regardless of the doctors medical judgment as to what is bets and also to impose "gag orders"on the doctors on revealing this. I believe there have been legal challenges on this last practice, not sure the outcome.

What fewer people know is that even the so-called indemnity plans like Blue Cross -- whose policy states they will cover all medically indicated procedures -- go behind the patients back and straight to the doctors office with threats which in turn cause doctors to adjust their medical care. Mostly this occurs with chronic illnesses. I used to work in an oncology clinic and we gor daily calls from Blue Cross demanding to know things like ïs the doctor considering another bone marrow transplant" and saying things like""we won't pay for another (bone marriw transplant, course of drug therapy etc) for this patient no matter what!". The doctor is then in a bind. If he thinks there is a chance the patient could afford to pay for the treatment he can tell him and let him (patient) decide if its worth going for given a likely figth with the insurance folks. But more often the doc is fairly sure the patient can't afford it, the pt & family already going through hel_l and then some and the doic just eeps silent and never mentions the treatment he would have given had the insurance folks not weighed in, figuring it will only make the pt & family feel worse to know that not "everything that can be done" is being done. Plus, the doc knows that if it gets back to the pt that the doc told them what the IC did, the IC has infinite ways to make the doc's life hel_l thereafter, and will do so.

The oncology clinic where I worked had 2 docs, 2 RNs, 1 lab tech and FOUR full time insurance paper filers/fighters. Costs of whose salaries (not much less than that of the nurses) of course being part of the overall cost of treatment. They eventually went u nder financially and were bought out by one of these assembly-line mass production clinics, which is a shame because the individualized care they were providing was vastly better than the assembly lines can.

[cigar7]

Can you please identify the Doctor, that peformed the surgery and made the recommendation?

[egeefay]

What fewer people know is that even the so-called indemnity plans like Blue Cross -- whose policy states they will cover all medically indicated procedures -- go behind the patients back and straight to the doctors office with threats which in turn cause doctors to adjust their medical care. Mostly this occurs with chronic illnesses.

We have Blue Shield.

When my wife had some ankle problems she went to see a doctor. He recommended an MRI. Blue Shield would not approve the MRI even though the doctor recommended it. (expensive)

Instead they wanted her to see a physical therapist. Since we have a high deductible we ended up paying for the physical therapist out of our pocket.

It was a waste of time. The physical therapy didn't help.

We've decided to go to Thailand and have an MRI done next time we are there. It's cheap enough and we'll get the doctor the information he needs.

As a result of the experience we increased our Blue Shield deductible even further to reduce our premiums . We now have only major medical.

Our plan is to go to Thailand for our routine heathcare needs and rely healthcare in the US only in emergencies.

I'd be interested in hearing from others who have decided to go this route

Edited July 15, 2006 by egeefay

[Sheryl]

I'd be interested in knowing the terms of your Blue Shield policy and whether it lets them refuse to pay for tests your doctor considers necessary...and what appeals channels are open.

These companies will keep on denying legitimate claims as long as people pay the premiums anyway and don't put up a fight.

[Topprofile]

Some update on this case.

I managed to get hold of a Claims Manager at Goodhealth and he pointed out some things with my claim. On my "Pre-Certification Medical Form" the Doctor has written the following:

1. Condition Requiring Treatment: Recurrent Tonsilitis

2. First consultation date: 31/3/06

3. Has this condition existed before: NO

4. Symtoms apparent from: 12/12/05

So these lines are somewhat contradicting themselves. However it took me 10 emails and threats to sue them and cancel my policy before they pointed it out. I guess I didn't read all papers to closely to pay attention to this.

Anyway I got the doctor to write a medical summary that I have today faxed to Goodhealth's claims department saying:

1. Condition requiring treament was "Acute tonsilitis"

2. Patient has had a soar throat in the past and after discussions with patient the chance of this recurring again is high and therefor decission to perform tonsillectomy was made.

We will see what Goodhealth comes up with this time.

Thanks all for your input.

[Topprofile]

Finally, yetsterday I got an answer back from Goodhealth saying they would accept my claim.

It took threats and 4 months to get to this.

After they read the Doctors written medical summary they changed their minds.

Thanks to Sheryl, Cigar7 and others who have helped.

//Rob

[Nawtilus]

See my other posts in another thread about BNH, give this hospital a big big miss is my only advice.

8k for a room, Bumgrad and Samitivej are cheaper these days for room only anyway.