Avon Family Wins Insurance Fight

Appeal reverses insurance company denial, forces them to pay $70,000

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    NEWSLETTERS

    Appeal reverses insurance company denial, forces them to pay $70,000 (Published Wednesday, Apr 2, 2014)

    In the last week of March, a long fight between Joe Eisenberg and his health insurance company came to an end. Nearly $70,000 was at stake.

    Last year, Joe’s 25-year-old daughter Hillary needed back surgery. The recommendation for disc replacement surgery came from her doctor after years of debilitating pain.

    The Eisenbergs' insurer, Assurant Health, denied the claim for the surgery claiming it was an experimental procedure. The company was only willing to pay for a procedure known as fusion.

    The Avon family opted to pay $70,000 out of pocket for Hillary’s disc replacement surgery in November of 2013 while at the same time fighting the denial from Assurant Health.

    The Eisenbergs moved ahead with the surgery hoping to ease Hillary’s pain and said it was worth risking every dollar.

    “I’m back at the gym. I have zero pain. I don't feel anything," said Hillary Eisenberg.

    Last week, Joe Eisenberg received the letter he had been waiting for. A third-party review board reversed the denial, forcing Assurant Health to pay for Hillary’s surgery.

    Eisenberg had a feeling he might win. It’s a battle he’s had to fight twice.

    Three years ago, Joe’s son, Eric Eisenberg, had the same procedure for the same problem. Assurant denied that claim for the same reason – that the surgery was experimental.

    The family paid for the surgery out of pocket and fought the denial, which was also overturned in appeal. The Eisenbergs didn’t expect the same fight twice.

    "If they can deny it, they're going to deny it because most people don't have the time," said Joe Eisenberg.

    We reached out to Assurant Health to ask about their denial being overturned.

    A spokesperson released the following statement:

    "Assurant health reviews each claim individually. We remain committed to following claims practices in accordance with all applicable state and federal regulations, as well as following industry and accepted medical standards. In the event a customers’ claim is denied, we communicate directly with them and provide our customers with information regarding the appeals process, including their right to request an independent third party claim review by the State of Connecticut Insurance Department."

    Joe Eisenberg compares fighting the denial to a nearly full-time job. His advice to anyone in the same situation is don't give up.

    “You can win,” said Eisenberg. “You just have to be persistent, really persistent, and not give up. You can't give up, because they want you to give up."

    The Office of the Health Care Advocate helped the Eisenbergs with appealing the denial. They tell the troubleshooters they have a 60-70 percent success rate with appeals.

    “In a lot of cases it’s simply a matter of getting the medical record put together and plugging it into the criteria piece by piece, line by line, said Demian Fontanella, General Counsel for the Office of the Healthcare Advocate.