POSTED: 6:30 p.m. EST November 12, 2003
UPDATED: 4:37 p.m. EST November 13, 2003
GREENVILLE — In 1970, Claudia Turner was Miss South Carolina. She competed in Atlantic City, was first runner-up in the competition and even became a spokeswoman for PET milk while raising a family.
But even then, a long battle had begun.
"My weight kept rising and I couldn't control it. I had to take medications that make you gain or retain weight. You can't lose on it and I gained a good bit. That's what really put me over the edge," Turner said.
Now, at age 52, Claudia Turner is 150 pounds overweight. Five doctors told her she needed a gastric bypass operation to eliminate or reduce a large number of medical problems, which will reduce her stomach to a small pouch. Gastric bypass is a drastic surgery in which most of the stomach is sealed off. It leaves a small pouch on top, which connects to the small intestine.
Her insurance company said no.
"The day I found out they had denied me, I had just been called before that with a surgery date. I had some crying time … I was devastated," Turner said.
Turner found help with Rob Hoskins, an attorney who specializes in insurance appeals.
"I cannot stress how important it is to take a claim seriously once it has been denied once. And seek legal counsel because that is where your case is going to be won or lost," Hoskins told WYFF News 4's Carol Goldsmith.
Here's how the appeal process works:
- If your claim is denied you'll get a letter from the insurance company. It must explain why you're denied. It will also give you an address where you can send a written appeal.
- You will usually be offered two appeals through the insurance company. If both of those are denied, most people, about 80 percent of the population, can appeal through a federal law called ERISA, the Employee Retirement Income Security Act.
- You can file a lawsuit, but under ERISA ordinarily you cannot call any witnesses and doctors or claimants can't testify. All the federal judge can look at is the record that was created during the appeals process.
- That's why it's important to get legal advice after that first denial to make sure you have all the information on record in case you have to file a lawsuit.
That's what Claudia and her husband did, and now her appeal is on the way to a federal courtroom.
"You have to wait until somebody decides whether you're going to live or die...and that is a horrible way to feel," Turner said.
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