UMR Health Insurance – 48 Reviews, Complaints & Ripoffs at

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In the Summer of 2015, when I was 56 years old, I spoke with my personal provider during a scheduled physical about some difficult and painful varicose veins I had in my right leg which were preventing me from exercising, having the ability to regularly sleep sufficiently to feel well rested, and which significantly contributed to an excessive weight gain. I was referred to a local surgeon by my provider and I verified that he was covered by my health insurance (UMR) to provide me with services with a UMR Insurance Representative. I have a family history of severe varicose veins along with a familial history of vascular and heart disease.

In October 2008 I sustained a myocardial infarction which resulted in surgery, hospitalization, and extensive cardiac rehabilitation. In 2010 I had similar veins in my left leg which were ablated through a radiofrequency ablation through the same surgeons office by another surgeon at the same Outpatient surgery center and called UMR and received no difficulty in having the procedure costs paid for. The employer and insurance through that employer that I had during the first surgery was/is the same as for the second surgery.

I informed the surgeon as I had the primary provider that I was intending to retire at the end of 2015 and that I wanted to take care of any significant medical issues prior to retiring. The surgeon agreed that this was a wise way to proceed and he informed me that 3 visits with him for visual assessment and a vascular ultrasound and photographs were necessary to meet the standards of the insurance company. On October 24th after the 3 visits with the surgeon and the vascular ultrasound and photographs were completed, the surgeon’s office submitted the information to UMR Insurance for Pre-determination of need and payment of benefits.

The surgeon’s office received a letter indicating that there was no need for this and that the procedure was covered under my employer’s insurance plan with the surgeon and the surgery center I intended to use. Approximately a week and a half prior to the intended surgery date (November 23rd, 2015) I contacted UMR Insurance and spoke with a representative. During the contact I made it very clear that if the surgery wasn’t going to be covered by UMR insurance that I would have to postpone it until such time that insurance would cover it because I did not have the available funds to pay for the procedure.

I repeated that I did not have the available funds to cover the costs of the procedure several times and each time was told not to worry. The representative assured me that the procedure was a covered procedure by my plan and the only question she had was to ask me if the surgery was going to be done in a hospital or in an outpatient surgery center. When I told her an outpatient surgery center she again reassured me that the procedure, the provider, and the intended outpatient surgical center were part of my plan coverage (indicating that it would be covered) and that I should go forward with my tentative plans for the surgery.

On November 24th (the day after the surgery was completed) a letter was generated by UMR insurance which I received the following Friday which was the day after Thanksgiving 2015. The letter indicated that the size of the vein which ablated was not 5.5mm at the saphenofemoral junction (I later found out through the surgeon’s insurance liaison that the size was over 5.3 at that junction and within 2 inches below the junction it was 5.7mm) and as such that the procedure and its costs would not be covered to the cost of $16,520.

The surgeon’s liaison also indicated that neither she nor the surgeon were aware of this measurement requirement at the point where it was identified. I have submitted the above information to UMR insurance along with a request for an appeal and have made numerous telephone calls to the UMR Representatives to be told that it is being reviewed and that the representative would get back to me which they never did. I have on more than one occasion requested that I be sent a written response to my appeal and I have only received an explanation of benefits notice denying my claim stating that it was not a covered benefit under my plan.

My last telephone call to UMR last week (Feb 26th, 2016) had me talking to a UMR representative, after waiting on the phone for 10 minutes who then hung up on me after she said she was going to transfer my call to another young lady who I had talked to 1 1/2 weeks earlier who said she would call me back in 2 days and in 1 1/2 weeks did not call back. The representative then later called me back threatening that she wouldn’t be able to help me if I hung up on her again. That representative stated that unless I submitted another appeal there was nothing they could do.

I informed her that in January 2016 I had sent in an appeal. She stated that because my initial appeal was received while the procedure and benefits were being reviewed another appeal would need to be submitted. I have sent this in as requested on February 27th, 2016.

To this date the insurance, although they have refused the claims for this procedure have covered/paid approximately $800 and negotiated a $2000 reduction in the surgeon’s costs and paid a little more than $590 to the outpatient surgery center and negotiated a $3452 reduction leaving me with $8168.00 to pay out of my limited monthly retirement pension. This process has caused me, my family, and my surgeon more than a little frustration.

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