Health insurance denied a procedure they said would be covered

[nicwright01]

Cross posting from r/insurance

We could use some help in coming up with the appropriate path for resolving a problem with our health insurance. Thank you in advance for reading and your suggestions. TL;DR at the bottom and important points bolded.

At the time of all events below, my wife was covered under my employer’s health insurance plan.

• Her doctors recommended a test to help them differentiate between 2 related diseases which would ideally help us determine treatment paths and assess options moving forward (e.g., surgical interventions are sufficient to resolve one condition but not the other).
• Our plan, provided by Aetna, doesn’t cover most genetic type testing, so I wasn’t sure if it would cover this specific test. I spent some time going through their coverage materials, but ultimately I was unable to find a specific answer to my question. To determine if it would be covered, I wrote to their automated help system with the name of the test, the test codes, and the reason that her doctor had ordered the test.
• Someone from their help center wrote back that the test (identified by codes) would be approved under our plan, provided we complied with all in-network procedures.
• On the basis of the test being covered, we had her take it, though we would have delayed or foregone the test had insurance not claimed to cover it.
• After she had the test, we received notice that her claim was denied because our plan does not cover investigative testing.
• Writing back to their system for clarification, I received an outline of the appeal procedures in addition to the “apology” that “We apologize that our representative sent you incorrect information”

Now I’m not sure what the appropriate next step is. We took action (getting the test) on the basis of their assertion that the procedure would be covered. However, from the look of it, any appeal will likely be denied on coverage grounds (i.e., they don’t cover investigative testing). Is there any way to get them to bear the burden of costs created, by their own admission, by the mistake of their representative? The total procedure cost is not trivial, but not super huge (just less than $1000), so cost effectiveness might come into play for some more adversarial options.

Not sure if it’s relevant, but the employer and health plan was in New Jersey. The test was conducted after our move to Texas.

TL;DR: Asked Aetna if test would be covered, they said yes, had test done, they denied it and apologized that they previously said it would be covered.

 

[teenforgod18]

@nicwright01 Usually the plan says that a misstatement on the part of a representative does not change coverage. Appeal it. They might decide to pay it.

Also if it was done in another state you may run into network coverage issues. I would appeal it and ask for your claim file and try to figure out exactly what's going on.

 

[nicwright01]

@teenforgod18 Thanks, we'll try the appeal. Lame that they can give misinformation and get away with it, but I don't know what else I expected Thanks for the info and response!