Complaints

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• Initial Complaint

  Date:11/07/2022

  Type:Service or Repair Issues
  Status:

  AnsweredMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  Answered:

  The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  Complaints 1. Claim secure unnecessarily delayed approval of a service for which there was coverage under the agreement 2. I believe they delayed approval to avoid payout as they knew that there was to be a service provider change in the near future. 3. Claim secure had previously provide preapproval at 100% coverage for the same service – addiction services for a 14-day detox stay – with no indication of “room and board only” – there was no bases for the denial of services 4. Poor communication – Many times I was told it was being reviewed by a manager, team lead or supervisor – 5. Delay in provide timely response or follow up with information 6. Denied coverage for service for which I was covered for under the plan. 7. Denial was fabricated as a ‘room and board’ only – this was never identified by customer service when requesting details as to coverage, was not an issue in 2019 when approved for a 14 day stay, and under the new provided (for which I am told through our employer coverage has not changed – and still refers to the claim secure booklet for coverage details) this is not the same outcome.

  Business Response

  Date: 15/07/2022

  It is important to note that ClaimSecure is not an insurance company, we are a claims payor and our clients are invoiced for all costs incurred by their plan. It is our duty to ensure the parameters of the plan are enforced to protect its viability for both our client the employer and their employees.

   

  The estimate for an addiction hospital stay was received on March 22, 2022.  The total estimated cost was $24,000. The coverage under the group plan is for the semi-private room only. That does not include treatment costs. The coverage clearly outlines ‘semi-private room only.’ ClaimSecure has encountered a number of facilities over the years who are capable of providing these breakdowns. After multiple attempts to clarify the difference in cost between room and board vs treatment ClaimSecure finally reached the Manager and a facilitator at the facility in question. Again they indicated a breakdown was not possible. At this point ClaimSecure could not approve the estimate as we could not determine which portions of the fee were actually eligible under the plan. The estimate itself was rejected on April 13, 2022 indicating it could not be approved without a cost breakdown.

   

  The member in question contacted ClaimSecure on numerous occasions to appeal the decision based on an estimate that was processed from 2019 from a different facility at a much lower cost of under $9,000. Unfortunately there were items also indicated as being included in the cost and a breakdown was not received. This estimate was approved erroneously; however, ClaimSecure clearly indicates on estimate letters that they are only valid for 12 months. In this case that would be the period from May 27, 2019 – May 27, 2020. At this point based on the member’s escalation, we attempted to receive authorization from our client to approve the estimate based on cost breakdowns  received from other providers previously. Unfortunately ClaimSecure’s contract with our client was coming to a close on April 30, 2022 and once that happens ClaimSecure is no longer able to approve or pay expenses on their behalf. In these situations where groups migrate from one carrier to another issues such as this are typically handled by the new carrier. The paperwork was passed to the new carrier on May 2, 2022 for reconsideration concluding ClaimSecure’s involvement in the case.

  
  

  Business Response

  Date: 19/07/2022

  As previously mentioned, the employer is no longer a client of ClaimSecure and cannot approve or pay any claims.  The paperwork was passed to the new carrier on May 2, 2022 for reconsideration concluding ClaimSecure’s involvement in the case.
  
  

  Customer Answer

  Date: 20/07/2022

  
  Complaint: ********
  
  I am rejecting this response because:

  due to there unnecessary delay in processing the claim to which I believe I had coverage for while under there services. I believe they purposely delayed responding to my concerns and addressing the claim as they knew there was to be a change over in claim providers. There is no accountability from the company for there fraudulent denial of a claim I had coverage for. 
  
  
  Sincerely, ******** ******