Claim Denied

[onawbtngr546]

Thank you for choosing United Healthcare for your healthcare needs. After a careful review of the claim submitted for emergency services on December 4, 2024, we regret to inform you that your request for coverage has been denied.
Our denial is based on the following findings:

• Lack of Prior Authorization:

Our records indicate that you failed to obtain prior authorization before seeking care for the gunshot wound to your chest. While we acknowledge the emergent nature of the situation, our policy requires that all non-preventative services, including “unexpected chest injuries,” be pre-approved through our 24/7 Prior Authorization Hotline. Unfortunately, our hotline received no such call during your ambulance transport or at any point before your admission to the emergency room.

• Failure to Prove Medical Necessity:

The submitted documentation does not sufficiently demonstrate that treatment for a penetrating chest wound meets the definition of “medically necessary.” Our guidelines specify that life-threatening conditions must be substantiated with a second opinion from a network provider, preferably before care is rendered.

• Alternative Options Not Explored:

Based on our retrospective analysis, alternative, more cost-effective treatment options—such as a virtual telehealth consult or at-home first aid—were not attempted prior to your emergency room visit. We understand that you were actively “bleeding out,” but this does not exempt you from exploring lower-cost care pathways.

• Out-of-Network Care:

The emergency room where you received treatment is not within our network. While City General is geographically closer to the location of your shooting, our network partner, DiscountCare Clinic, is only 25 miles away and equipped with staplers and gauze for such injuries.
Next Steps: You may file an appeal within 30 days if you believe this decision is incorrect. Appeals must include:

• A notarized letter from the attending physician, explaining why you thought you were entitled to not bleed to death while waiting for approval.
• Evidence that your injuries were, in fact, serious enough to merit immediate attention, such as photos, videos, or live reenactments.

We encourage you to familiarize yourself with your plan benefits and utilize in-network providers for future incidents. Please do not hesitate to reach out to our customer support team if you have questions about this
Sincerely and in good health, United Healthcare
P.S. Remember: Preventative care is the best care! If you’d like, we can help you schedule your annual physical or connect you to a mindfulness seminar to prevent future traumatic injuries.

[Devo]

Or it makes a good cover story, my first thought.

[onawbtngr546]

Thank you for your recent appeal regarding the denial of coverage for your emergency room visit on December 5, 2024. We have carefully reviewed the additional information you provided, including the attending physician’s notes, photographic evidence of your gunshot wound, and the security footage of the event.
After a thorough re-evaluation of your case, we regret to inform you that the original denial decision has been upheld. Our reasons for this decision are outlined below:

• Insufficient Documentation Supporting Medical Necessity:

While we acknowledge the physician’s statement that your “life was in immediate danger,” we remain unconvinced that the treatment you received in the emergency room was the only appropriate course of action. Specifically, we find the decision to intubate and transfuse blood unnecessarily aggressive when other cost-effective options, such as applying firm pressure to the wound with a clean cloth, could have been attempted first.

• Failure to Contact Prior Authorization Hotline: Your appeal asserts that you were “unable to call” due to being “unconscious” after sustaining the gunshot wound. While we empathize with your condition, we remind you that our Prior Authorization Hotline is available 24/7 and can be contacted by a friend, family member, or even a concerned bystander. The failure to delegate this responsibility during your medical emergency further substantiates our denial.

• Out-of-Network Services: As stated previously, City General Emergency Department is not part of our network. While we understand that DiscountCare Clinic is 25 miles away and does not operate ambulances, the choice to seek care at a non-network facility remains inconsistent with your plan’s cost-saving guidelines. Our analysis indicates that driving oneself, despite injury, or calling a rideshare service might have provided a viable and more affordable alternative.

• Policy Exclusions on Firearm-Related Injuries: Your plan explicitly excludes coverage for injuries resulting from “unapproved use of firearms.” As no evidence was provided to confirm the shooting was accidental or unavoidable, we are unable to overturn this aspect of the denial.

Next Steps: This decision is final. You may choose to escalate your appeal to the Independent Medical Review Board (IMRB) at your own expense. If the IMRB overturns our decision, you may be eligible for partial reimbursement minus a $5,000 “Claim Reconsideration Fee.”
We encourage you to consult our Member Handbook to better understand your plan benefits and avoid similar misunderstandings in the future. Should you find your current coverage unsatisfactory, we invite you to explore our new UNH UltraBasic plan, which offers even fewer benefits at an even lower premium.
Sincerely and in good health,
United Healthcare
P.S. Please note: Our appeals process is designed to promote proactive healthcare decision-making. While this unfortunate incident did not meet policy requirements, we commend your efforts to stay alive and wish you a speedy recovery.

[onawbtngr546]

We are deeply sorry to learn of the unfortunate passing of Mr. Super Important CEO. Please accept our condolences during this difficult time. While we sympathize with the circumstances, our role is to ensure that all claims adhere to the terms and conditions outlined in the health plan agreement.
After a final review of the appeal and associated medical records, we must reiterate that the denial of coverage for the emergency room services on December 5, 2024, remains valid. Below is a detailed explanation of our decision:

• Adherence to Policy Requirements:

As outlined in Mr. CEO’s policy, any emergency care must be pre-approved through our Prior Authorization Hotline. Although we understand that Mr. CEO was incapacitated at the time of the incident, this requirement applies regardless of the patient’s physical condition. Failure to meet this fundamental condition regrettably voids eligibility for coverage.

• Lack of Cost-Effective Alternatives Considered:

Despite the life-threatening nature of Mr. CEO’s injuries, the decision to seek care at City General Emergency Department remains inconsistent with the cost-conscious ethos of our plan. As stated previously, DiscountCare Clinic, while 25 miles away, could have provided appropriate treatment at a significantly reduced cost. While we acknowledge that Mr. CEO succumbed to his injuries en route to City General, this does not alter the plan’s requirement to seek in-network care whenever feasible.

• Non-Compliance with Documentation Standards:

While the attending physician documented extensive measures taken to save Mr. CEO’s life, the records fail to demonstrate that all avenues for stabilizing the patient at a lower level of care were exhausted. For instance, there is no evidence that home remedies such as pressure application or the use of an adhesive bandage were attempted prior to initiating high-cost hospital interventions.

• Posthumous Denial Justification Clause:

Section 8.7(c) of the policy explicitly states that “denial of services rendered in violation of plan terms shall not be overturned by the outcome, including but not limited to mortality.” While we regret Mr. CEOs passing, this outcome does not exempt the services rendered from the policy’s requirements.
Final Resolution: This decision is considered final and binding. No further appeals will be reviewed. The patient’s estate remains responsible for the full cost of the care provided, which totals $1,117,394.09. A 10% discount is available if payment is received within 30 days.
We extend our deepest sympathies to Mr. CEOs’s loved ones. If you have any questions about this decision, or if you would like to explore alternative payment plans, please contact our Member Services Department at 1-800-DENY-NOW.
Sincerely and in Good Health,
United healthcare
P.S. Please note that United Health Plan offers a wide range of affordable options to meet your healthcare needs. We would be happy to discuss plans for surviving family members to ensure they avoid similar missteps in the future.

[Devo]

Very nice, so, you support murdering CEOs if you don't like their medical policies?

[winn dixie]

Originally Posted by Devo

Very nice, so, you support murdering CEOs if you don't like their medical policies?

Good grief

[onawbtngr546]

No surprise people here aren't talking about this. Other CEOs who own all the news stations don't want to glorify the obvious reaction the public is having to one of their own being beheaded. Bet nobody knows what those three D words are even in relation to... hah

[Salty Again]

Originally Posted by onawbtngr546

No surprise people here aren't talking about this. Other CEOs who own all the news stations don't want to glorify the obvious reaction the public is having to one of their own being beheaded. Bet nobody knows what those three D words are even in relation to... hah

... Okay. ... You made a valid point.
Thanks fer the explanation, mate. ....

#### Salty

[onawbtngr546]

My m8, didn't even read the news did you lol

[HDGristle]

This is not the way and the shooter needs caught, tried and sentenced. For some he'll be a folk hero. Not me.

[Jacuzzme]

You don’t like insurance companies so glorify hunting company executives in the street? WTF is wrong with you people?

[tommy156]

The sad part is health insurance companies shouldn't even exist, and they don't in any of the other big boy countries on earth. These companies are literally just an unnecessary middle man taking your money and giving you nothing for it in return.

Countries with universal healthcare never try to "repeal and replace" it, and the people in those countries live longer, healthier lives than we do.

We've been snookered by the man. Tricked into thinking we have it good here. We don't. The proof is in the patient health outcomes.

[Jacuzzme]

Speak for yourself. My health insurance is great.

[tommy156]

Originally Posted by Jacuzzme

Speak for yourself. My health insurance is great.

So is mine, but the insurance company itself is completely unnecessary. They are only there to enrich themselves by getting in between the patient and the caregiver. They serve no necessary purpose.

Only in America is healthcare left to the profit motive. In every other country on earth, they actually take the Hippocratic Oath seriously.

[1#Ratt]

Originally Posted by tommy156

The sad part is health insurance companies shouldn't even exist, and they don't in any of the other big boy countries on earth. These companies are literally just an unnecessary middle man taking your money and giving you nothing for it in return.

Countries with universal healthcare never try to "repeal and replace" it, and the people in those countries live longer, healthier lives than we do.

We've been snookered by the man. Tricked into thinking we have it good here. We don't. The proof is in the patient health outcomes.

Try visiting some of these countries and see how "great" the actual universal healthcare works.
for example, there are approximately 378 MRIs in Canada in the USA we approximately 13000