Florida Blue ignored my claim — could you get them to answer me?

Alan Wolfson’s claim for post-operative equipment hasn’t been processed for almost a year. What does he have to do to get Florida Blue’s attention?

Question: I was insured through the health exchange with Florida Blue for 2015 and part of 2016. I had surgery last December. The surgeon wrote a referral for post-operative medical equipment for my rehab.

I followed the Florida Blue instructions from its site and mailed the forms as directed, but nothing was ever processed. I have made numerous phone calls to Florida Blue and have been passed around from one department to another. They’re clueless.

I have been asked to mail the forms to two different PO boxes and still after months and months, Florida Blue claims to have never received any of my documents. Repeated phone calls to supervisors have yielded no answers.

It has been nine months and I can’t even get Florida Blue to acknowledge receipt of the documents and process or deny the claim. This is very frustrating. Can you help me get a straight answer from Florida Blue? — Alan Wolfson, Delray Beach, Fla.

Christopher Elliott

Christopher Elliott is an author, journalist and consumer advocate. You can read more about him on his personal website or check out his adventures on his family adventure travel site. Contact him at chris@elliott.org. Read more of Christopher's articles here.

  • Ben

    This claim needs to be escalated to the state insurance commissioner and attorney general.

  • AJPeabody

    Use registered or certified mail, return receipt, to resend the requested information. Any complaint to the insurance commissioner should be both to Florida’s and to the state where you were when you bought the insurance.

  • Zarkov505

    Use Registered Mail.

    Most businesses have special handling for Registered Mail, as it is frequently the last warning before litigation is filed.

  • taxed2themax

    This for me is two separate issues; not acting on the claim and the denial.

    I think the larger one – the one for me that is least defensible is the no-reply/no-action.. That said, what I don’t know for fact is this… was the claim properly submitted and documented in accordance with the insurers claims standards? If so, then to me the no-action is a pure failure.. If not, then that I think is something different .. but that alone does not mean the whole matter is the insured fault. I think the insurer still needs to make all efforts to assist the insured to complete the process to the extent possible..

    On the second part, the denial.. that to me is more objective.. Did the documented claim fall within the policy provisions and wording? If so, then that’s a problem.. If not, then a denial is correct and I can’t fault the insurer for doing so.

  • michael anthony

    Good points. A good many denials are due to coding errors. And most insurers are loath to correct them. (Coding problems can also occur on the physicians end too, at which point the insurer points to u, to fix).
    As for denials, there should be an appeals process. And it should be clearly spelled out in your “rules” book. Of course times to submit are short, (wonder why, ha!). I had a similar case and wrote directly to the state head of the department of health. I pointed out VERY NICELY that I knew it was not their jurisdiction, but my health was being compromised. Within 7 days, case fixed and I has what I needed. Unorthodox, but it worked.

  • taxed2themax

    Agreed.. There are lots of places and ways that errors can occur.. Some are on the patients end (and I define coding as the patients end because for me I tend to want to limit the scope of the relationship and information reach to outside/non-patient parties) and some are on the insurers end.. However, I think there needs to be a clear path to getting them identified and fixed timely.
    I also agree with the need for an appeals process. While I tend to like objectivity, I cede that in some cases this may not always be possible — so having a review/appeals process to insure that the correct decision has been reached when all facts are known, is a good thing for all… and that does also mean if further information comes to light that makes a previously ruled valid claim, a now denial, that too should be allowed.
    But in this case, for me the larger error if you will was the apparent difficulty in getting to whatever the decision was going to end up being – yes or no. However, not all “it took a long time” cases are the insurers fault because of issues that really are the domain of the insured… but even then, I’d expect a clear path to getting them resolved so that a adjudication can be made.

  • Kairho

    Florida Blue is just naturally obstreperous. Had them for several years (and hated them) until we went on Medicare (and Humana) and learned how [comparatively] good an insurance company could be. They still inundate us with junk mail but never again.

  • joycexyz

    The old stonewall technique! Very popular among insurance companies, particularly health insurance. I remember our adventures years ago with my late father-in-law’s insurance. The first response to a claim was “we never received it.” After resending, it was “we need more information.” Third response: “we never heard of the claimant.” Fourth response: “he’s not covered” (totally untrue). They just try to wear you down till you give up. We never did, and prevailed in the end.

  • cscasi

    There is absolutely no reason Florida Blue shouldn’t have responded to the claim in a “reasonable” amount of time. I know my insurance companies normally process a claim received within ten to fourteen days; perhaps a bit longer if it is complicated and has to go through a different process and reviews. Nonetheless, I believe one should expect a response in no more than 30 days; even if it is just an acknowledgment stating it is being processed but is going through further examinations (or whatever).
    I am online with Medicare, my secondary insurance and even Tricare for Life, so I can see if and when the claim has been received, if it is in process and if it has been completed. If it has been completed, I can see the Explanation of Benefits. If I see something I feel is incorrect or I have a question about, I can call someone in the claims department and ask questions. I will say that there has been a few times over the years when there was a coding issue or something missing; or even the insurance company needing additional documentation from the provider. When I know that there is additional information needed form the provider, I ask what it is and I immediately follow up with the provider to ensure it gets the necessary information to the insurance company so it can complete the claim. I will say that I am retired and I have time to stay on top of my claims as well as those of my wife (time,which lots of working people may not have) and doing so has helped us get issued resolved in a timely matter over the years.
    I certainly cannot believe Florida Blue has been this bad with Mr. Wolfson. I am glad Chris managed to get an answer for Mr. Wolfson. While it was not one that he wanted, perhaps the reason could have been that the post operative medical equipment was not covered under his plan or he had not met the annual deductible. Or perhaps his doctor needed to write a better justification. Who knows without further details being provided.
    Florida Blue certainly needs to get its act together in its claims processing department, rather than just saying it knows it has deficiencies and will address them.

  • PsyGuy

    You need to file your claim with the state insurance commissioner, though regrettably that doesn’t mean you should or would get your claim honored.

  • PsyGuy

    Very true, often you can get your complaint to the legal department and into a real person’s hand/desk just by sending registered mail.

  • PsyGuy

    Well sure there is, if you just take claims and throw them away it’s a lot cheaper than processing them.

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