Destiny Healthplan and Guardian effectively practice medicine without a license, by refusing to pay claims based upon the advice of staff who have NEVER examined the patient(s). Despite one doctor's multi-page submission of reasons why a 'TENS' device helps people like my husband (with his chronic back pain), Insurance company refused to pay for it. They form 'opinion' without ever examining husband, who coulddid benefit from device. THIS is just one example. They refused to pay other claims for OVER a year, and THEN claimed it was 'too late' (that bills were being submitted after some sort of deadline). The doctor had submitted the bills EVERY MONTH. Later, insurance firm claimed to never have received the doctor's claims, despite having issued denials throughout the prior period. Effectively, they denied them every month until a time at which they could say the claims were 'too late'. The result: we owed doctors over 5K that SHOULD have been covered. Also, they have plan to pay some Rx's as 'chronic illness' medications. There is NO rationale for the medications chosen, and medications I've taken for over 5 years aren't considered 'chronic'. It would seem the reasoning has more t do with prices of drugs, OR rather, drugs that they can CLAIM are 'cheaper' to entice employers into signing on. Lastly, they defer some decisions (like approval of Rx's) to OTHER companies so they can claim it 'wasn't their decision' in refusing to pay, or in asking us to pay 200 for an Rx that should be 'in network'. Bottom line: The three-party arrangement and other firms involved are all just clever ploys to AVOID PAYING (or to claim they never got the claims because it went to 'the other firm'). Lastly: They costed me HOURS AND HOURS spent in pharmacies and on the phone from home, and could've caused my death when they refused to cover an Rx I had been on for over 5 years. Out of network would have cost 365, which I could NOT have paid because I'm on disability. Only by threatening to sue was I able to get my Rx's. THAT is NOT acceptable.
