Peffer Heating and Air, Inc.

Ms [redacted] was covered under our Atlas policy which is issued on a non-admitted basis to The Atlas/International Citizen Group Insurance Trust out of Hamilton, Bermuda. The insurance is underwritten by Lloyds, London and HCC Medical Insurance Services (HCC MIS) is the administrator. HCCMIS have...

reviewed the claims concerning this matter. On 3/9/20105, we received the additional information that was previously requested. While the receipt of this is outside of the timely filing guidelines set forth in the policy, HCCMIS will make an exception and reopen the claims in question. We will reprocess these claims as eligible immediately and have them sent to repricing. Ms. [redacted] will receive new Explanation of Benefits shortly. I hope this information will allow the Bureau to conclude the handling of this file. If I can be of any further assistance, please let me know. Sincerely, HCC Medical Insurance Services

We have reviewed Ms. [redacted] file and issues in her complaint. Unfortunately, the services and treatment were excluded under her policy. Consequently, her claims were properly denied under the terms and conditions of her policy. I hope this information will allow the Bureau to conclude the...

handling of this file. If I can be of further assistance, please let me know. Respectfully, [redacted]

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted] and find that this resolution would be satisfactory to me.  I will wait until for the business to perform this action and, if it does, will consider this complaint resolved.
Regards,
[redacted]

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint.  For your reference, details of the offer I reviewed appear below.We provided filled and signed claimant's statement and authorization form on November 25th of 2014 using few different methods: fax and through HCC customer account with Cisco Registered Envelope Service, however there was no reply on a fax anda reply with secure message that there was no attachments. Then we sent it again, adding our email to CC of the message, there was no reply. I'm attaching filled and signed claim form, proof of transmitted fax with hospital bill and claim form.BTW, they never sent us any letters this summer asking to fill any claims form. They dont have any proof of mailing it. The same way they treat any other customer who would write a complain, it's all over internet, bunch of complaints about this company with exactly same problem - They never mail any claim form to anyone to fill until enough time will pass so they can send letter explaining that case is closed due to lack of information. After they will offer to reopen the case, but will never accept any documents.They also never provide any names of the customer service representative who would talk to you.Anyway, claimant's form is attached as well as medical bill.
Regards,[redacted]
[redacted]

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
Pre-Authorization from HCC Insurance letter dated March 12, 2014 approves for Certificate number [redacted] and Authorization number [redacted] for procedure Uterine Fibroid (diagnostic code 218.9) and Dysmenorrhea (625.3.) on May 16th 2014.  During authorization process HCC was well aware this was for Uterine Fibroid and gave authorization for the procedure that came out as Uterine Fibroid (diagnostic code 218.9) and Dysmenorrhea (625.3.) which is exactly what they approved.  If this diagnosis was not covered under the policy then why/how could they authorize and not let anyone know (not even the patient) they were approving what they now claim is not covered on their policy.
Regards,
[redacted]

Thank you for your patience as we reviewed Mr. [redacted] situation. Mr. [redacted] claims were processed correctly under the terms and conditions of his policy that he purchased. I hope this information will allow the Bureau to conclude handling of this file. If I can be of any further assistance,...

please let me know. Respectfully, Charles [redacted], Esq.770.693.6585c[redacted]@hcclife.com

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
Regards,
[redacted] response 2/24/15HCC has a very well documented internet history using excuses not to pay on thier policy  HCC has deemed my condition: pre-existing,,...when A]--the top expert in connectcut,Dr Wu,liver expert [published] Uconn john dempsey , still has no exact diagnosis for me ,the known is its a liver problem,I asked him about pre-existing,,,he stated his job is not for insurance companies,his job is to fix meB]I never in my entire life had an esophageal bleed,this is what I was hopitalized for , C] HCC has also deemed my hospital stay non emergency ,even though I almost died , D]HCC insisted follow up procedures be done at a hospital facility,instead of outpatient,the hospital was much more expensive,done only at HCC demands,and they still havent paid.significantly increasing costsE]HCC-pre approved EGD services for doctors offices,that they now are not payingF]Anthem,the company I replaced HCC with when I learned how bad HCC is,has paid every claim submitted,some are days literally away from cliams HCC hasnt paid,and some are claims HCC did not pay [i had double coverage 11/2014]G] to date HCC has not paid one dime,on all the claims they have recieved,using every excuse that can be thought of,non emergency-pre-existing [thier favorite] lack of records , lack of documents,lack of additional steps takenH] I personally provided my med records to HCC via registered mail,on burned CD"s,hence,lack of records,and no pre-existing esophageal bleed ever,is well documented,I was taken by ambulance to sharon hospital,in ICU for days,this was an emegency,regardless of HCC opinion of the matter...near death..to me , is an emergency Overall,HCC has a reputation of using excuses,,,coding issues , and any possible method not to pay , my only truly pre-existing condition is I was born,I have elevated all HCC claims to appeal level 1 , I will progres to level 2 , then level 3 with the state of CT insurance commision , if resolve still cannot be met,litigation will definitely be opened against HCC by me,Lawyers,,,tend to resolve things,the list of complainants against CC is huge,there are entire websites about them and HCC techniques used not to pay claims...HCC needs to grasp,this IS NOT going awayAny simple internet search will find more cases than countable..of folks having problems with HCC paying claimsto resolve this, HCC needs to pay the claims sent to it regarding this matter,if this reaches litigation,damages will be sought.
[redacted]2/24/15

HCCMIS did pre-certify the medical procedure as the medical services were determined to be medically necessary. However, as is indicated in the precertication letter mailed to both the provider and insured, precertification does not guarantee coverage or payment of claims or benefits. See the below language from the precertification letter. Pursuant to the policy, this precertification letter does not guarantee coverage or payment of claims or benefits. This determination will be made only after complete claims information is received. Eligible Medical Expenses will be paid subject to all Policy terms, conditions and exclusions and the member's plan of benefits at the time services are rendered. To confirm benefits, please review the Certificate or call the toll-free number listed on your member ID card. Based on the above and the full review of the claims submitted, HCCMIS correctly denied the claims as they are not eligible under the policy. Consequently, we are upholding our decision in this matter. I hope this information will allow the Bureau to conclude handling of this file. If I can be of any further assistance, please let me know. Sincerely, HCC Medical Insurance Services

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
[Provide details of why you are not satisfied with this resolution.]
Regards,
[redacted] Still no answers...

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
I dont see any proof of mailing or faxing the letter you have attached, to Kaiser. Copy of the letter without proof of mailing or return receipt in this case cannot be considered as a proof that you mailed this letter.   Letter dated July 1st of 2014 and HCC was suppose to receive ALL medical records of [redacted] long time ago. It is clear that this letter was never mailed out by HCC, therefor Kaiser did not provide you with any medical records. Your copy of so-called "letter" you provide is bogus and never was mailed to us, not to the Kaiser.  Kaiser doesn't have any records of any requests from HCC to provide copy of medical records for [redacted].    Since we sent the claim form multiple times in October, November and December of 2014 and few times in  January to you, using fax, secured emails, through clients portal on your website, this signed form even attached to our complaint with Revdex.com (id # [redacted]) but no one want to see that files were attached, we decided to take further action and file a lawsuit against HCC Medical insurance services, LLC, and name responsible following individuals: [redacted], President Andrew [redacted], Vice President of SalesBryant [redacted], Assistant Vice President of MarketingCharles [redacted], Esq Harding [redacted] Amount of this claim will allow us to use Small Claims Court of Santa Clara County in California, since we've done business with your company while being in Santa Clara County. It will help us resolve the matter much faster than through Revdex.com or your customer service, which doesn't help, or being absolutely unprofessional, violating every single rule of Business and Professional Code, by not providing their names, contact information, employee ID #'s, not keeping any information in a system about the insurance claims, etc.   I'm attaching the proof of emailing through your portal and faxing to you our claim form and this will be last time we communicating with you before filing a lawsuit.    Sincerely, [redacted] and [redacted] 650-[redacted]

Mr. [redacted] was covered under our Atlas policy which is issued on a non-admitted basis to [redacted] out of Hamilton, Bermuda. The insurance is underwritten by Lloyds, London and HCC Medical Insurance Services (HCCMIS) is the administrator.
HCCMIS has...

re-evaluated the 7/25/14 and 7/26/2014 claims submissions for Mr. [redacted]. Upon review, we agree with Mr. [redacted] that these claims were incorrectly denied and should be considered eligible for payment (subject to deductible and coinsurance). We will reprocess these claims immediately and have them sent to repricing. We apologize for the delay and inconvenience encountered by Mr. [redacted]. Mr. [redacted] will receive new Explanation of Benefits shortly.
I hope this information will allow the Bureau to conclude the handling of this file. If I can be of any further assistance, please let me know.
Sincerely,
 
[redacted]
HCC Medical Insurance Services%3

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
This was NOT a pre-existing condition. The irony is that neither I nor the providers know the cause of excessive belching and bloating. My only pre-existing condition was stones in the gall-bladder. That condition is being confused with belching and bloating. I will go to any length to prove the truth. If it was a pre-existing condition then why did HCCMIS give me pre-approval for colonoscopy/upper endoscopy? Why didn't HCCMIS know while giving approval that they will not cover the cost of the procedure? WHAT IS THE POINT OF A PRE-APPROVAL if the costs are not covered at all? Please enlighten me.HCCMIS should refund all the premiums I paid if they are not going to pay for legit medical procedures/tests which were NOT about any pre-existing condition. Based on symptoms you can call any illness a pre-existing condition and hence keep making money by ripping people off! This issue is not settled and I 'll take every possible route to prove the truth.
Regards,
[redacted]

We have reviewed the issues raised in Ms. [redacted]s complaint. Her coverage has a very limited benefit for this type of treatment. We informed Ms. [redacted] of the information needed to reconsider her claim on December 24, 2014. To date, that additional information hasn't been received.
If we do...

not receive the requested information, the claim will be closed.
I hope this information will allow the Bureau to conclude handling of this file. If I can be of any further assistance, please let me know.
Respectfully,
 
[redacted], Esq.

We have reviewed the issues raised in Mr. [redacted]'s complaint concerning his wife's policy. We had previously mailed our request for a claimant's statement to the address Mr. [redacted] used when he purchased the coverage. When the requested information was not received, her claim was closed. If Mr....

[redacted] wishes to appeal our decision, he should submit a claim form and the medical records from the provider. We will consider Ms. [redacted]'s claim after our review of her medical records to determine if her treatment is a covered expense under the terms and conditions of her coverage. If we do not receive the requested information, the claim will be remain closed. I hope this information will allow the Bureau to conclude handling of this file. If I can be of any further assistance, please let me know. Respectfully, Charles [redacted] Esq.

Ms. [redacted] was covered under out Atlas America policy which is issued on a non-admitted basis to the Atlas/International Citizen Group Insurance Trust out of Hamilton, Bermuda. The insurance is underwritten by Lloyds, London and HCC Medical Insurance Services (HCCMIS) is the administrator.
HCCMIS received the Claimant's Statement and Authorization form as requested. HCCMIS then requested the medical reocrds from the providers that treated Ms. [redacted] on 8/5/2014. However, based on the medical records we received, the records indicate that Ms. [redacted]'s abdominal pains started on Saturday (8/2/2014). This would pre-date the insurance effective date of 8/4/2014. The coverage has the following exclusion:
Exclusion:
Pre-existing Conditions — Charges resulting directly or indirectly from any Pre-existing Condition, as herein defined, are excluded from this insurance, except charges resulting directly from an Acute Onset of Pre-existing Condition, as herein defined, are covered for all Members subject to the limits set forth in the Schedule of Benefits and Limits.
Definitions:
Preexisting Condition: Any (1) condition for which medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) was recommended or received during the 2 years immediately preceding the Certificate Effective Date; (2) condition that had manifested itself in such a manner that would have caused a reasonably prudent person to seek medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) within the 2 years immediately preceding the Certificate Effective Date; (3) injury, illness, sickness, disease, or other physical, medical, mental, or nervous conditions, disorder or ailment (whether known or unknown) that, with reasonable medical certainty, existed at the time of application or within the 2 years immediately preceding the Certificate Effective Date. For the purposes of the Complications of Pregnancy coverage offered hereunder, Pregnancy will not be included within the definition of a Preexisting Condition.
 Because symptoms'began prior to the effective date, the claim has been correctly denied as a pre-exisiting condition.
I hope this information will allow the Bureau to conclude the handling of this file. If I can be of any further assistance, please let me know.
 
Jon P[redacted]
HCC Medical Insurance Services

Mr. [redacted] was covered under our Atlas International policy which is issued on a non-admitted basis to the Atlas / International Citizen Group Insurance Trust out of Hamilton, Bermuda. The insurance is underwritten by Lloyds, London and HCC Medical Insurance Services (HCC MIS) is the administrator....


I apologize that Mr. [redacted] has had difficulty reaching our facility. We have been working diligently to get the providers in Canada to respond to our requests for an itemization of certain of his claims. To date, we have been unsuccessful. However, we are waiving those requirements and proceeding to adjudicate his claims on his behalf with these facilities.
I hope this information will allow the Bureau to conclude handling of this file. If I can be of any further assistance, please let me know.
Respectfully,
[redacted]

Ms. [redacted] was covered under out Atlas America policy which is issued on a non-admitted basis to the Atlas/International Citizen Group Insurance Trust out of Hamilton, Bermuda. The insurance is underwritten by Lloyds, London and HCC Medical Insurance Services (HCCMIS) is the administrator.
HCCMIS...

has received claims from Ms. [redacted], however, the Claimant's Statement and Authorization forms that have been received by HCCMIS have either been incomplete or not signed by Ms. [redacted]. Forms submitted by [redacted] cannot be accepted since they were not appropriately signed by Ms. [redacted]. The Claimant's Statement and Authorization form may be completed and signed • electronically via the ClientZone by visiting www.hccmis.com. Until the Claimant's Statement and Authorization form has been full completed and appropriately signed, HCCMIS is unable to reopen Ms. [redacted]'s claims.
I hope this information will allow the Bureau to conclude the handling of this file. If I can be of any further assistance, please let me know.
Sincerely,
 
[redacted]
HCC Medical Insurance Services%3%3

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution would be satisfactory to me.  I will wait until for the business to perform this action and, if it does, will consider this complaint resolved.
Regards,
[redacted]

Revdex.com:I have reviewed the response made by the business in reference to complaint ID[redacted], and have determined that this proposed action would not resolve my complaint.  For your reference, details of the offer I reviewed appear below.I have reviewed the policy definition of Pre-existing conditions, and I do not agree that the services received from Park N[redacted]t are included in this definition. The reason the MRI was ordered by the doctor was to rule out a possible tumor or other growth. I have never had such a condition in my life. I would like HCC to pay this claim ASAP to myself in the form of a check.Regards,[redacted]

Revdex.com:I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint.  For your reference, details of the offer I reviewed appear below.Since the last BBC email, HCC Life Insurance Company informed us that they wanted the records from the optometrist of our son. I contacted the optometrist, secured the records and emailed HCC the complete records on the 9th of January. In the email I indicated that the single page being sent represented the entire records file the optometrist's office has for our son. I called HCC on the 15th of January to get the status and they informed me they are waiting on records from the optometrist's office. I informed them I had sent the complete records by email. They said that they only received (1) page. HCC chose to ignore the communication in the email that the single page represented all the records that the optometrist has for our son. Additionally they ignored the fact that I had sent the records to them. They did not call to verify that the single page represented the entire file for our son. I had to call to find out that they had labeled the file as incomplete/awaiting records and were again indefinitely sitting on our claim. HCC informed me that they could not accept receiving the optometrist's records from me. They stated that the optometrist's office would need to form a letter indicating that the single page of records for my son represented all the records they have for him. Then the optometrist's office would need to fax the letter with the single page of records directly to a new fax number that HCC gave me. I contacted the optometrist once again and they graciously faxed both the letter and records for my son, to the number HCC gave us, on the 20th of January. I spoke with HCC Life Insurance Company this morning (27th of January) and the claims department is "reviewing" our claim. So we are in the same situation that we were when we initially filed our complaint in December of 2014. HCC Life Insurance Company continues to delay their "review" and processing of our claim. The services provided to our son occurred nearly 6 months ago and we are currently being threatened with being sent to collections by multiple entities. Additionally every statement/bill I receive from the medical providers I call them to give an update. Multiple have indicated to me that when they have called HCC Life Insurance Company and HCC has indicated to them that they cannot process the claim because they are waiting for me to fill out a "Claimant's Statement and Authorization Form". HCC provides this form to us to fill out for any particular incident or condition. In fact I had filled out and sent in this form a long time prior to the providers calling HCC. I spoke with [redacted] of HCC and he informed me that indeed they had received this form a long while back and that I could have any of the providers call him direct to verify that. This was appreciated but doesn't change the fact that blatantly incorrect information has been given to the providers which has complicated my working with them to put off payment due dates while HCC "reviews" our claims.Regards,[redacted]