Saturday, December 21, 2013

Insuring Disaster

Legend has it that the first insurance claim to be rejected was when Adam had a rib removed. GOD, the top representative of the carrier (it only had one participant) denied the claim as being elective surgery, not part of HIS plan.

Not much has changed since then. It often feels as if we are walking through a labyrinth inside a maze in trying to decipher the signs leading to the holy land of coverage. Exhausting deductibles, reaching maximum out of pockets, meandering from primary care physician and through the Alice in Wonderland of pre-authorization codes, not daring to cross state lines, feeling as much out of touch as out of network, by the time the requested treatment occurs we are often in dire need of medical attention for a pounding headache and a sudden urge to throw ourselves out the window.

Let me be perfectly clear, this in not intended as an indictment of the Affordable Care Act. This morass is a product of a flawed system where private companies are given control and financial incentive to play the push me-pull you game that serves their bottom line very nicely, thank you.

Carriers are switched from year to year as loyalty has no place in this extraordinarily unhealthy health care system. The challenge is always to be sure that at least one doctor whose name you recognize is within the ever shrinking list who have agreed that you and your insurance company are worthy of their time and effort.

For many years (or as my wife would put it, too many years) I have been insured as a group of two, myself and my assistant/officer manager/bedroom partner. Within the past several weeks our lousy existing policy, riddled with ever increasing reasons why the money for any possible treatment would come out of my retirement fund, arrived in the mail. The premium had risen (as surely as the sun does each morning).

The first alternative was to search the internet for signs of hope through the federal website. After waiting for the dust to settle from the roll-out fiasco, I was confronted with the unalterable reality that small business solutions were not going to be easy to find for 2014. But, as the used car salesman says, wait there's more.

Early last week, word filtered down that a husband and wife, as the only two employees, no longer qualified as a small business.

And so, the hunt for a solution intensified. On to the individual exchange and a whole range of choices that went from bad to worse. For us, there would be no federal subsidy to help alleviate the pain. So, before settling for next to nothing while forking out an awful lot, my wife and I decided to make certain that the rumor about the axe for the husband/wife coverage was true.

It turns out that we seemed to know more about this situation than the insurance experts or most of the people in the employ of our state

Finally, in desperation, we went to the one source least likely to give us a straight answer, our present insurance company. And this is how my wife relates the call:

"You know that this was one of those, "this call may be recorded for training purposes" conversations. After I explained our status I was told: "Yes, technically you are not entitled to this policy, but since you have been issued a renewal notice it will be effective unless you get audited. And even then, which shouldn't take place until at least March, you will be able to get a different policy"". WHAT?

If I have it right, my wife was being advised that she would be entering into an agreement with the company to accept coverage we knew was in violation of the law. We should hope they (meaning the representative's company) never caught up to us, but we shouldn't worry if that happened. Unless of course, we were then informed that they had advised us ("we have the tape") that the policy should not have issued. "We will be  denying your claim in its entirety."

Oh, you think that couldn't happen. Just ask Adam, who was certain he had received pre-authorization from HIM.


Richie Jay said...

The one part of this that you got wrong is the refunding of premium payments. They might deny the claims based on the rule violation, but I assure you that they would never EVER offer to return a penny to you for the privilege.

Robert said...

Medicare for everyone plus the right to buy insurance for them limo services. Too simple for the pols


Robert said...

That is the answer but clearly not the solution as the insurance industry lobby combined with the Republican hatred of "hand-outs" creates an impenetrable barrier to reason.