AIG Critical Illness insurance - claim denied due to pre-existing condition?

Question

Hi,

My husband's kidney function recently got down to 12% and now he has ESRD - End Stage Renal disease. This requires him to be on hemo-dialysis. He has Critical Illness insurance through his employer that is supposed to pay him $20,000 for a critical illness like stroke, heart attack, cancer, and organ failure. So, we filed a claim and it was almost immediately denied. The denial letter said that the reason for denial was that this was a pre-existing condition. I called them because this was obviously a mistake, because his kidneys had never failed before.
This is what I was told: The kidney failure was due to diabetes and the diabetes is a pre-existing condition because it was diagnosed in June of 2012. I read the policy and it was very confusing and not clear. I can appeal but I don't know what to do or what to say. They basically said I'd have to find a doctor that says that his kidney failure was not caused by diabetes.
We are so frustrated and so disheartened by this. Any help or advice would be greatly appreciated. We have pre-paid legal and they weren't very helpful. Has this happened to anyone else? Is there any recourse? His employer's HR department weren't much help either. They never bothered to explain this could happen. Why not disclose this plainly before letting their employees sign up for such a plan? We've been paying high premiums thinking we were covered, but I bet ANY critical illness he has will be linked back to diabetes and not be covered. *sigh*

A Hunch · Accepted Answer

These supplemental plans are generally not "company benefits".  The insurance company (in this case AIG) tells the employer we will give your employees a discount on this insurance, IF you pull the costs as part of a payroll deduction.

That's the only connection to the employer.  The employer is not responsible for actually administering the plan like they would for health and life insurance benefits.

Pre-paid legal is completely useless.  I have never known anyone who got a single valuable piece of information from it.  All they do is send you some literature that you can look up yourself on the internet.

The insurance company told you what you needed to have the situation approved.  If the doctor will certify this, than the insurance company would pay.

Are you familiar with the book The End of Diabetes by Dr. Joel Fuhrman.  It's $12 on Amazon.  You should read it.  Better lifestyle = elimination of type 2 diabetes; eliminate type 2 diabetes = these secondary conditions improve.  It's all common sense but it goes through the medical evidence about it.

Note: 
"but I bet ANY critical illness he has will be linked back to diabetes and not be covered. *sigh*" the insurance company is not saying that the ESRD is not covered because he has diabetes.  His ESRD would be covered if your husband had purchased the critical illness insurance BEFORE being diagnosed OR the pre-existing condition waiting period had expired (if there is one).

StephenWeinstein · Answer

No, he'd have to have kidney failure that wasn't caused by diabetes.  Finding a doctor to say it is not enough.  It has to be the truth.  Finding a doctor to lie is not enough.

The insurance company is right.  I don't know why HR didn't explain it more, but it's really not their job.  Your supposed to read the policy when you get it, and ask questions then if it isn't clear.

? · Answer

Sorry this is confusing, but it doesn't change anything.

Unless you could show the kidneys suddenly failed due to a specific AND sudden cause, then you don't have a case.

Cathi K · Answer

Most all insurance has pre existing condition clauses. I agree with A Hunch about Dr. Fuhrman. Since changing our diets my husband has been taken off all his medications. I have seen really amazing results.

Maurita · Answer

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RE:
AIG Critical Illness insurance - claim denied due to pre-existing condition?
Hi,

My husband&#39;s kidney function recently got down to 12% and now he has ESRD - End Stage Renal disease. This requires him to be on hemo-dialysis. He has Critical Illness insurance through his employer that is supposed to pay him $20,000 for a critical illness like stroke, heart attack,...

Anonymous · Answer

2

gray · Answer

1

Anonymous · Answer

I couldn't just sit around and do nothing like my doctors suggested.

They didn't want me to do anything or to take herbs or herbal remedies, but I had to try something - they just wanted me to do dialysis!

This program allowed me to take control of my health. I went from Stage 4 to Stage 3 kidney disease.

It was easy to do and my BUN, creatinine and anemia are all in better ranges.

Reversing Your Kidney Disease?

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AIG Critical Illness insurance - claim denied due to pre-existing condition?

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