Monthly Archives: September 2006

Definition: “Health insurance is a type of insurance whereby the insurer pays the medical costs of the insured if the insured becomes sick due to covered causes, or due to accidents”.

How on earth are you supposed to know what is covered and what is not? There is one sure fire way that I think everyone has discovered at some point and that’s actually require medical treatment and put in a claim. They are very quick to tell you what is NOT covered.

I went to an ENT (Ear Nose Throat) specialist some time ago and was diagnosed with “obstructive sleep apnoea due to obstruction both at the level of nose and palate; the effect of this over an extended period of time will be to lead to right sided heart strain and hypertension, and even heart failure”. Although very painful, this condition is easily rectified with surgery with a procedure called a “uvulopalatopharyoplasty”. Try and pronounce that!

So I submitted my claim for specialised medical review at the insurance company and surprise surprise – DENIED, “The uvulopalatopharyoplasty is not considered essential for the necessary care and treatment of an injury or sickness. This coverage decision was made based on the general limitation under your plan which states, “No payment will be made for expenses incurred for you or any one of your dependents for charges for supplies, care, treatment or surgery which are not considered essential for the necessary care and treatment of an injury or sickness, as determined by ***** ************.”"

My question to the insurance company is simple, “if right sided heart strain and hypertension, and even heart failure is not essential for the necessary care and treatment of an injury or sickness, what exactly do I have to be dying from in order to make this policy work for me?”

It’s in appeal now with a barrage of information that I submitted along with a lengthy covering appeal letter and further substantiating documentation. Even if I don’t get my way, I hope to at least bore them to tears!