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Insurance company pre-approves surgery then refuses to pay after the fact

Insurance company pre-approves surgery then refuses to pay after the fact (Photo: KUTV)
Insurance company pre-approves surgery then refuses to pay after the fact (Photo: KUTV)
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(KUTV) The simple act of walking the dog was a brutal exercise for Kristine LaMay a couple of years ago. A sharp pain in her right knee was killing her.

Her doctor recommended surgery to fix the pain.

LaMay knows better than to just assume it will be covered, so she made sure her insurance company, Select Health, was on board. Sure enough, she got a letter saying the procedure is "approved."

But now, nearly a year after the procedure, Select Health says they are not going to pay.

"They're saying that the surgery was experimental,” LaMay said.

She appealed, pointing out that it had been pre-approved. Select Health agreed to pay about half, but that's it. LaMay is on her own for the rest, approximately $10,000, she said.

She wants to know how her insurance company can go back on its word.

"I followed all the rules and they aren't doing what they said they'd do," she said. "I would never have had this surgery if they denied it. I had the surgery because they pre-approved it."

In an email, Get Gephardt asked Select Health spokesperson Jamee Wright, "Why is Select Health not paying for a procedure that was preauthorized? What more could this family have done to make sure the procedure was covered?” and, “What should select health customers do in order to make sure a preauthorization will be honored after the service has happened?"

Wright responded: "We do not have a comment."

When Get Gephardt followed up asking, “Why are you refusing to answer the questions?"

Wright did not immediately respond.

A spokesperson for the Utah Department of Insurance said it is especially-rare for an insurance company to pre-approve a procedure then change its mind after the fact. The department encourages LaMay, and others in a similar situation, to file a complaint and allow them to investigate.

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In the meantime, LaMay is out a whole lot of money and says she now has a shaken faith in an insurance company with which she's never had a problem before.

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