A few months ago I woke up and had a severe sore throat. I had a temperature of approximately 102F. My throat hurt and it was hard to swallow, breathe and eat. I felt that there was a lump in my throat that I could not swallow. Being that my PCP office was closed, I decided to go to the Emergency Room for treatment.
At the Emergency Room, the Doctor told me I was suffering from a bad case of Strep Throat. He finished treating me and I went back home. I had missed two days of work due to my throat infection. A few months later, I get a bill from the hospital saying that I owed them $3715 dollars. I felt there had to be a mistake, so I called and found out that PJP Health Agency had declined to pay the claim for service rendered. I spoke to two different employees in the financial department of the hospital and both of them said that PJP Health Agency was the worst at paying claims. They said PJP Health Agency is the only company that requests every single piece of paperwork relating to your claim and they scrutinize it in an attempt to not pay.
I called a customer service person at PJP Health Agency and he offered no help. The impression I got was that he and PJP Health Agency did not care about me as a member at all. He was very un-caring and almost seemed bothered that I was trying question the reason my claim was denied. I asked to speak to a supervisor and he told me there was no one that I could talk to. I told him that there had to be someone I could talk with about my situation and he said you are talking to me.
He told me that my claim was denied because I went to the Emergency Room for a non emergency situation. I was told that my only course of action was to file an appeal in writing. I wrote a very detailed letter as part of the appeal process and submitted it to PJP Health Agency. After a few weeks I received a letter from PJP Health Agency that once again they chose to decline my claim. The letter stated that an "Average lay person" would not have felt my health/safety was in jeopardy and would not have deemed this an emergency.
The funny part about their reasoning is—it is incorrect. I have spoken to several "Lay people" such as co-workers and people have come in contact with and everyone has said they would have gone to the Emergency Room. This is the reason I felt my situation was an emergency. When I was 16 years old, I had an infection in my throat known as Epiglottis. I had the same type symptoms, including the lump in my throat, as I did in August. My parents took me to the ER and within a few minutes, I passed out due to lack of oxygen. I was rushed into the operating room and en emergency tracheotomy was performed. My parents were told by the doctor that if I would have been a few minutes later getting to the hospital, I would have died. I spent 2 weeks in the hospital with a tube in my throat so I could breathe. I now have a nice scar on my neck as a reminder of my ordeal.
How am I to know what they are going to consider an emergency PRIOR to going to the emergency room? If I knew what was wrong, I might as well have prescribed my own medicine too. I equate my situation to someone that is having chest pains, shortness of breath and other symptoms. He goes to the hospital thinking he may die from having a heart attack, but is told at the hospital that it was just gas. So I guess in this case PJP Health Agency would not pay because it
was a non-emergency.
The bottom line is, I work very hard for a living and I paid PJP Health Agency my payment every month. I am not one that misuses the heath care system or takes advantage of anyone. I just feel that I should not have to be scared or hesitate to go get medical attention because of fear that I won't be covered. Based on my situation and reading other comments, I feel that PJP Health Agency has their profit margin as their number one priority and not its members. I plan to appeal this with the State of New Jersey HMO appeals process. If that does not work I will contact the New Jersey Insurance Commissioner. I will also contact and make complaints to anyone and everyone that will listen.
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