While at a different company I sought treatment for my development of discomfort due to my large breasts. I visited a local doctor who suggested a reduction surgery would alleviate some of this. AT THE TIME OF MY APPOINTMENT I WAS INSURED.
Not even two weeks after my initial appointment, my company shut down, and we had to empty our desks same day. Thankfully I had enough other options to begin employment just two weeks later with another company and enroll in their (then) carrier PERFORMAX.
Due to my new company's policies, I was not able to enroll until after a month— which is still better than many other companies. I was enrolled less than two weeks later, but did not begin coverage until "after the next full month."
As I had began turning the wheel for this procedure, my doctor's office then sent in to PERFORMAX for PRE-DETERMINATION— basically geeting their approval to perform the surgery and determining if it was medically necessary. They then sent me THREE letters (and my Doctor as well) of pre-determination.
Once I had the surgery, three weeks later they denied the claim based on "lack of prior coverage" and a pre-existing condition. Here's where they will get you: Even though I was "enrolled" two weeks after my prior coverage ended, my actual benefits start date wasn't until 65 days later. They said that they consider it a "break in coverage" because it was over 63 days (by 48 hours), and as far as they're concerned I had no prior coverage.
I understand company policy but: WHY WOULD A COMPANY SEND THREE LETTERS OF PRE-APPROVAL and NOT have researched if they considered the employee's prior insurance in their benefit determination??? And WHY has it been over six months and two appeals, and Peter Cacciola (Claims Department) still hasn't spoken with me directly and I have to harrass the Customer Service Department? And WHY would a large company like PERFORMAX deny a claim (After approving it three times), and make a gradudate student pay thousands of dollars that they assured her they would take care of?
PERFORMAX is a "passing the buck" company that does not research its claims properly and the consumer ends up fronting the bill. I was once a believer in insurance, and now I am not— they are "snake oil salesmen" making you promises they don't intend to keep, and then avoid your inquiries afterward. PERFORMAX gives a bad name to an industry that sells itself on protecting people from such expenses— then leaves them with the bill after the premium is paid.
My company no longer works with PERFORMAX, and I hope yours makes the decision against it as well.
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