Tuesday, July 15, 2008

Behind the Scenes

As a consumer, I fully understand the frustration with not having the insurance company I need. In fact, we are between coverages at the moment because we can't be covered across state lines in the same program. In my search for Tennessee coverage I discovered a horrible truth. I fall between the cracks.

Here's the scenario. I have Blue Cross. In Indiana it is an elected coverage I buy for which I qualified without a hitch. In Tennessee it is an elected coverage but also the state run program for those who are ineligible for coverage by other companies. So if you can't be covered in Tennessee, BC will do it, theoretically.

That being said, though I've been a member of BC for a year, my Indiana coverage won't transfer to Tennessee. There are two reasons for this. First, crossing state lines means a transfer of coverage resulting in triple the cost I paid in Indiana. Secondly, I'm not in the height/weight ratio required for a transfer (ie/ I'm plump). I asked what weight and height I'd have to be and was declined an answer as there are those that would attempt fraud.

For Indiana coverage to transfer then, while I'm completely healthy with no other issues (no diabetes, high blood pressure, etc) I'm not eligible for coverage due to my ratio. BC told me to call their offices for the uninsurable in Tennessee for coverage. I did so and the answer I got was that I don't qualify for uninsurable coverage. Why? Because the only thing wrong with me is my weight. If I had a condition, then I would be eligible. Folks, this is the same company. Between state lines I fell through the cracks. One state says I'm not healthy due to my weight, the same company in a different state says I'm healthy despite my weight. I should be mad, right? Frustrated?

Okay, I confess to frustrated, but not at the insurance company. I'll tell you why. The insurance industry is a go-between. It is the mediator between you and another entity. When you are hired, it's between you and your employer. When you are unemployed, it's between you and the state where you reside. Insurance companies have a TON of plans. Everything from individual to group to third party administrators (where the plan is administered by your company specifically and the insurance party does no more than determine coverage for a claim).

This is where you say, "Geez, Kelly, isn't that what I'm talking about? The insurance company decides if I'm sick enough or sick with the right thing. Baaaad insurance company." Ahh. This is true BUT, and this is a huge but, each of those three categories of coverage (individual, group, and TPA) have many, many policies under each. YOUR COMPANY decides which policy they buy based on what they think the biggest coverable issues are. THEY decide, not the insurance company. The insurance company would be happy to sell their most thorough plan.

Here's how it works. Your company, state, or your pocket book tries to figure out what would best cover their particular issues and under what circumstances. They cover x surgery but not if x is associated with y. Or they cover x with this many days recovery. Or they cover x if it is not work related. Or they cover x if you haven't been diagnosed with x in the past (fill in the blank because this time period is also determined by your employer) months. ALL OF THE VARIABLES are negotiable by your company.

I worked for Prudential, Fortis, Assurant, Hartford. These are fantastic companies in the industry and it's ALWAYS THE SAME. It is really easy to blame the insurance company but what is actually happening is, your company purchased a policy of their choosing and time frame from the insurance carrier. Now the Insurance carrier is LEGALLY OBLIGATED to give your claim due process so that if fits the plan the company purchased. They are not allowed to cover you for things which the policy from your employer binds them on. THEY CANNOT. They also cannot ignore pre-existing conditions or waiting periods. Not because they are mean, but because they are legally bound to do so.

Other inside info? They don't have to read you your policy. Read it yourself. Know what plan you signed up for and ASK QUESTIONS. There is not a single company that won't explain it to you if you ask and all of them keep meticulous records. If you asked a question and it wasn't explained, have them pull up the voice file and fight. All phone conversations are recorded. Not just some. If you don't understand your waiting periods, ask. Read your policy. It's a contract and you signed your name to it agreeing to the conditions. Would you sign your name to a house mortgage without knowing your rate or term? No.

Your claims person is also obligated to work within a time frame. Every so often a notice must be sent out to you whether or not your claim is being worked on. But standards require that your claim be "touched" within the first 30 days. It's a law. Communicate with your claims handler. The harder they have to work to get information out of you, the longer it will take to get paid because they have to dig for it. If they ask you for a doctor update, get them one. Make sure your doctor has a signed HIPAA release on file and he/she knows that they should take the calls when they come in.

I sound mean. Sorry. This is a truth about the industry. My situation is based on my contract with the state and what the state (as my pseudo company) offers, not what the insurance company offers. Remember the insurance company wants to earn money and the more thorough the policy the better for them, however, they are bound by contract to offer you only what they've been permitted to offer.

You know the Afflac commercials? Why do you think the duck is telling you to tell your company about their plan which covers so much? Because the insurance company wants your company to offer it. If they don't, the duck can't help you. Talk to your employers, tell them what you want. Get a group together if you have to.

This is just the facts. Make an informed decision about your coverage and then work with it to get the best coverage you can. If you have two or three choices, look at them and see what you want covered. But the insurance company isn't the bad guy. They're just the accountants.



  1. Still not convinced that SOME don't try to manipulate coverage to their own ends, but for the most part, correct. The person to grouse at is not the insurer, but the one who decided on the policy.

  2. Excellent post and even better points. But the bottom line is, no matter which policy you have, the insurance company will do everything in their power to pay as little as they can, so unless your company offers a comprehensive plan, it will fall on you (and your pocketbook) to either make up the difference or find a good supplement. You mentioned Afflac, which is a wonderful supplement, but at my current job the cost for coverage makes it seem almost not worth it... until I get hurt, lol.

  3. I won't change everyone's mind with a single blog. But if it gets you thinking correctly toward the owner of the policy, my work is done here. ;)

    Insurance companies get their money from the company, not from the claim. You could try blaming doctors too, or those people who rip off hospitals or don't pay their hospital bills, or even the malpractise insurance doctors have to buy.... it all filters down, doesn't it?

  4. They pay what they have to. In fact, there were often times my coworkers and I were TOLD to allow something which wasn't covered as a good will gesture to the client.

    IE/ The lady who worked as a receptionist and had ALL HER TEETH PULLED. That requires recovery before impanting or dentures can be placed. Her coverage said that if it didn't directly affect her sedentary occupation (sitting 90% of the time) or her speech there was no reason to pay. It didn't affect her speech and she could still take calls, but she felt bad about greeting people with a smile.

    Okay, stop chuckling. Here's the thing. Her coverage said, NO. WE said yes and paid it with full recovery benefits. While it wasn't critical to her JOB or her OCCUPATION, we were able to say that smiling was the unspoken understanding and therefore eligible.

    Often times the claims examiner TRYS very, very hard to pay you. We want you better so that you don't keep leaving work for other services related to the initial illness. That's the way it works.

  5. Excellent post. Now... if they would only write it all in English...

  6. LOL. You're just asking for too much there, lady.

  7. Ver interesting. Thank you Kelly. I find it outrageous that BC wouldn't cover people because of their weight. My mother had been covered by BC for years. They have been great. Last year she spent almost six months, on and off, in the hospital and they covered everything. We would have been broken without it.

  8. Employers are stuck, too, though. The HR reps genuinely want their employees to have the best policy available--healthy, happy employees are good for productivity and the bottom line. But those "pays everything" programs are waaaaaay too expensive for most companies or employees to afford.

    And Kelly, you might talk to my sister-in-law about insurance companies' willingness to pay for covered expenses. She has *lots* of experience fighting those battles over and over and over again.

  9. We should all read the fine print carefully AND ask questions. Remember when I mentioned depression? I had it bad. Hospitalization and all kinds of awful stuff. The insurance premiums were hideously high and I felt like a burden to my family because of this crap.

    We have Blue Cross and I worked out something since it had been so long ago. One quick visit to the doctor and his evaluation and suddenly, I got the same rate as the rest of the family. They were very good about working with me.

    Personally, I still have problems with insurance companies but I believe pharmaceutical companies and hospitals and doctors are to blame as well. The whole system is awful.


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