ComplaintsforClaimsecure

• Initial Complaint

  11/07/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  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

  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

  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 response

  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, ******** ******

• Initial Complaint

  04/02/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  Date of services received were July 31, 2021, and August 17, 2021. Receipts total approximately $800. Problem - I submitted my receipts before year end December 2021. The company replied to my submission and denied the reimbursement because they said that I missed the November 30, 2021. I contacted the company by email and telephone. I had a couple email exchanges where they simply refused to further examine the issue because I missed the deadline. The phone contact has not been responsive. I explained in to the phone rep that the company does not provide any notice of when the deadline to submit receipts is, and in this absence, it is reasonable to assume the deadline is year end. The rep said it is not their fault that I didn't know the deadline, and that I should have asked. * ** *** **** ******** ** ****** ** * **** ********* ** ************

  Business response

  14/02/2022

  Hello,

  On January 4th, 2022, we received receipts for claims with services dates of prior to September 1, 2021. According to the terms of your plan you have 90 days from the start of the school year to remit your receipts from the previous school year.  This means that the cut off to submit the receipts was November 30th, 2021.  Unfortunately we cannot pay these claims.

  Regards,

  ClaimSecure

  Customer response

  16/02/2022

  
  Complaint: ********
  

  My school enrolment was September 2020 - August 2021

  The dates of the receipts are the following

  April 26, 2021, April 28, 2021, June 15, 2021, June 29, 2021, July 13, 2021,July 31, 2021, July 20, 2021, Aug 17, 2021,  Aug 19, 2021

  I mailed the receipts Dec 28, 2021, express.  

  There was no due date provided for receipt submissions, which is intentionally not provided so that you can deny claims, as done here.  

  
  Sincerely,
  
  ****** ******

• Initial Complaint

  01/09/2021

  Complaint Type:

  Product Issues

  Status:

  Resolved

  More info

  *** **** ******* *** ****** **** *** **** *** **** ** ********** *** ClaimSecure rejected, for the 2nd time, my claim for an elbow brace refund. And are requesting that I send them a 3rd claim, including "Brand name and model number". From claim ONE, a complete invoice was sent by me ********* *****, generated by ****** and with the identification number there (**** **********). This 2nd Claim Number **********. The 1st Claim Number **********.

  Business response

  08/09/2021

  Hello,

  We have looked into this matter and have found that the invoice submitted did not have the make or model number for the brace.  The latter is required to determine that the brace has the components required to be eligible under your plan.  We found the make and model by searching the ****** site and have found that the brace you purchased does not have rigid stays.  As a result, I regret to inform you that this item is not covered.

   

  Regards,

  ClaimSecure

  Customer response

  09/09/2021

  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.
  
  Sincerely,
  
  ******** *******

*Some consumers may elect to not publish the details of their complaints, some complaints may not meet BBB's standards for publication, or BBB may display a portion of complaints when a high volume is received for a particular business. ↩