Voluntary Benefits Sometimes Need Advocacy

Does your company offer voluntary benefits like cancer insurance? If so, these employees and retirees may need advocacy services just as much as those covered by your health insurance.

This came to our attention recently when I helped a wife whose husband died of cancer in December 2008. He had purchased cancer insurance 11 years earlier through his employer.

In February 2008, the 54-year-old man I'll call Mr. C had been diagnosed with lung cancer. He underwent chemotherapy, radiation treatment and had one inpatient hospital stay. The insurer paid Mr. C directly under the cancer policy without issue.

Unfortunately, his condition worsened and he was admitted to the hospital again in November 2008 with septicemia and pneumonia—symptoms directly related to his cancer.

After his death, Mrs. C filed a claim to the cancer insurance carrier. This time, they refused payment. Mrs. C was in shock, wondering how payment could be denied for her husband's days in the hospital under the cancer insurance policy when he had just died of lung cancer.

The insurance carrier explained that it denied the claims because the hospital admission wasn't for cancer treatment. While both the septicemia infection and his pneumonia were byproducts of the chemotherapy treatment for his cancer, his main diagnosis wasn't cancer.

Mrs. C contacted Benefit Advocates to help appeal these denials. This was a case where we felt the insurance carrier was doing all they could do to deny a rightful claim for benefits. As our first cancer insurance case, we were resolute in our goal to get these claims paid for Mrs. C.

We reviewed the cancer policy in minute detail. We contacted the hospital and doctor. We obtained medical records of her husband's hospital stay and a letter from his oncologist outlining why he had been admitted to the hospital and the reason for his death. We obtained a death certificate. The primary cause of death was septicemia, but the secondary cause was lung cancer.
We reviewed medical literature on his condition and completed a legal search of any court cases filed that were similar to Mr. C's.

Fortunately, we found a lawsuit filed in Utah in 2005 with facts very similar to his case. We compiled all of our findings and filed a formal appeal to the cancer insurance carrier. We won the appeal on Mrs. C’s behalf—a decision that brought closure, peace of mind and saved her thousands of dollars.

Though she still grieves for her husband, Mrs. C can take comfort in the fact that the premiums paid for more than 11 years were not in vain. She received the coverage they bought and, most importantly, she didn't have to suffer yet another loss.

Our advocacy service is available to all clients’ employees and retirees for any type of insurance—not just health insurance. As we all pay more for benefits, remember that we're here to help. Your employees and retirees don't have to take 'no' for an answer.