Update - Furious at our Insurance Company

vlagrl29 · October 2013

I go in for a sinus infection last month....nothing out of the normal. I get an EOB from the insurance company requesting I send them 3 years of medical records from my family doctor office. Apparently they need to determine if my sinus infection is a "pre existing" condition. WTF! Since when did this become a pre existing condition. I'm sure millions of people every year go in for exactly what I did. I was so mad I posted about it on facebook and a GF of mine who has worse sinuses than I do got the same letter from a different carrier. Do you think this is happening because January is around the corner and they can't pull that pre existing card anymore? I don't want to send them that much medical info on myself. I think that is just to much privacy they are wanting. We pay the premium and they don't want to pay out for something simple.

ETA - a customer service rep called me this morning because they found out I wouldn't send my medical records. Apparently they need them or other claims I have may be denied. She told me that they would need medical records even if it was just a cold! I call Bullshit on that. I told her I talked to a manager last week and my doc will be resubmitting the claim for what i really had and that it's not chronic. I asked "you need medical records for a cold?", she said yes and I told her I wasn't comfortable sending them for a cold and if I had to talk to a manager again I would and she stopped pushing it and we ended the call. My daughter has gone in for a cold and they didn't need medical records for that! I've been on individual insurance before and have never dealt with this and what we have is good coverage and a reputable company that I've been on before. SMH

hoffse · October 2013

Yes I absolutely think this has to do with January.

Consider this: health insurance is not something that was meant to exist as a right (wait, bear with me here); it was meant to exist as a business. Health insurance companies are not obligated to exist. They exist to make money. They exist because they can make more on premiums than they pay out in claims.

Well when their costs go up because they now have to hedge for pre-existing conditions they can no longer ask you about, your costs go up also, and they scramble to grandfather in everybody they can under the old rules. Otherwise, they would go out of business. I'm going to go out on a limb here by asking this question, but if you were running the ship, would you do anything different? I wouldn't, and I'll admit it.

Even if we all agreed that universal healthcare is a right, health insurance is really not - they're two different things that we have so thoroughly merged in our screwed up system, that to get one makes us all think we require the other. Have you ever wondered why it was insurance that got regulated and not things like hospital overhead costs, procedure costs, drug testing costs, etc.? I have. Did you know that dollar for dollar, our health care costs (not insurance, but actual costs) are the highest in the world? By two and half times the next highest? And that figure holds true, even when you take into account the fact that other countries have higher taxes to subsidize healthcare? It's insane.

I'm sorry they didn't pay out the claim, and I agree it's frustrating. But I think we can expect more of this while health insurance companies figure out how they are going to offer both competitive premiums against other insurance companies and hedge against things they haven't had to hedge against before.

This is exactly like banking - when the fed makes it more expensive for banks to borrow money, the banks have to make it more expensive for you to borrow money... because banks are businesses. For some reason, everybody seems to know who to blame when it comes to rising interest rates. The healthcare thing is so screwed up, though, that it's hard to see where the problem really stems from - insurance companies? the government? healthcare costs themselves? Probably all of the above. And unfortunately we have a system that's so expensive that for anybody to afford healthcare in the US, they need insurance. And for insurance companies to be able to afford to exist under the new rules, they have to raise premiums and pull stunts like this. And so on and so forth.

vlagrl29 · October 2013

It is very frustrating. I do have a history of sinus infections because I have a deviated septum, but it's like not paying out when someone needs their allergy meds. I will be calling tomorrow morning. If they won't even pay out for a normal doctor visit I don't think it's worth us even buying health insurance anymore and just offer the doctor cash when we go in. Go to the county health dept for free vaccines for DD when she needs them. I understand they need to make money and I have a feeling the ACA is a huge gift to the insurance companies and that makes me really sad. I need a drink

hoffse · October 2013

Yeah I get it - I do wonder if the ACA was a gift for insurance companies, though. My firm does a lot of work with a couple smaller ones, and while I don't do healthcare, the folks that do have said it's been nothing but a huge PITA for those companies to figure out how to make this work. All the old algorithms have to be thrown out, they have all spent a fortune in consultants and lawyers to teach them how to comply with the new rules, etc.

And of course, the cost of that gets passed on to you and me. In the long run it might play in the health insurance companies' favor, but I think there's still some uncertainty about that in the industry. And at the very least, it's going to be awhile before they get the hedging right, and they may very well lose a lot of money while working out what the formulas should be.

I remember when all this was being debated - and it seemed so obvious to me that if you want to make healthcare accessible and universal, you lower the cost of it or else stop funding pork and instead divert those funds to subsidize healthcare costs. In other words, follow the models of every other developed country in the world. But you DON'T make it more expensive for insurance companies - because that makes the entire system (given the way we do it) more expensive. So in our effort to make it more accessible, we are making it more expensive and therefore less accessible. Doesn't that just make perfect sense?

I'm pretty conservative (100% because I'm cheap and no other reason) but even I think it's fine to have subsidized healthcare - I mean, we're America. We shouldn't have people dying from totally preventable things because they can't afford it. We don't live in the third world, and we should really be leading by example in this sort of thing. So I really thought it was a great problem to address back when it all got started... but then their "solution" was just ludicrous.

vlagrl29 · October 2013

I couldn't agree with you more and I'm pretty conservative too because I'm cheap

I will be going to yoga this morning and then I'm going to call the insurance company when I get home. I will be taking lots of deep breaths.

brij2006 · October 2013

They are fishing for a pre-existing condition. It's very unfortunate, but with the new ACA, it has health insurance companies not wanting to pay out anything between now and the end of the year. Like @hoffse said, the health insurance companies are a business and need to make a profit in order to stay afloat. Beginning January 1, there will no longer be pre-existing exclusions or anything, which will cause the insurance companies to insure people that they normally would not.

Look at it like this.... When it comes to auto insurance, someone with a DUI is going to pay a lot higher premium than someone with no tickets or accidents and good credit. That is how the auto insurance companies stay afloat and stay in business. The higher a liability, the higher the premium. Now with health insurance, they have to charge the same premium for someone who is perfectly healthy, and someone who has a very expensive disease. The only way for them to still stay in business by doing this, is to increase everyone's premium across the board. It is very unfortunate that they are being forced to do this, but it's the only way they will be able to stay in business.

@vlagrl29 If you feel that you are paying too much for health insurance, go onto the ACA Marketplace and get a quote for insurance. You may qualify for some assistance. However, if you or your husbands' employer offers health insurance, then you are required to take that insurance (since they're supposed to pay for 60% of the cost beginning June 1, 2014). But if you do not. For a family of 3 with an income of $19,530-$78,120, you will receive some assistance through ACA. So it's worth checking into if you do not have health insurance through your employer.

vlagrl29 · October 2013

I don't feel we pay that much. I honestly like the plan, its just because we buy our own (self employed) we get all the pre existing shitty clauses. We pay $200 a month and I already looked online at the ACA stuff and we would pay double than what we pay now.

I did call and find out the doctor billed it under "chronic sinus infection, rhinitus". I asked for a manager right away and she suggested I call the doctor back and have them re-submit it for something "acute" if I don't have it that bad. I get a sinus infection every year and 1/2 ok, so it's not chronic. I'm not sending them medical records for the last 3 years, they already have enough of that. So hopefully this can get taken care of easily.

I seriously think we would be better off if we banked the $200 a month for medical expenses every year for ourselves. But now of course we would get a tax penalty, but maybe we buy a cheap plan for in case of emergencies and then bank the rest. I'm just fed up. I understand they need to make a profit like any other business but hell I go to the doc maybe twice a year, DH never goes and DD goes for her yearly check ups and if she is sick.

brij2006 · October 2013

Have you ever thought about looking into a major medical policy with an HSA?

You pay a lower premium for the major medical policy that has a higher deductible (think $5k-10k), but then you also have money that is put into an HSA (Health Savings Account) each month. You can then use the money from that HSA to pay for a visit like this. It can also be applied toward dental, vision, prescriptions, your deductible, etc. Also with the new ACA, even those major medical policies are supposed to cover preventative care like PAP's, Mammograms, checkups for your child, etc. So you would basically be self-insuring without having the penalties or if something major would happen.

I work at an insurance agency that deals mostly with farmers. So they're all pretty much self-employed, and that is the type of policy that works best for someone like that.

vlagrl29 · October 2013

brij2006 said:

Have you ever thought about looking into a major medical policy with an HSA?
You pay a lower premium for the major medical policy that has a higher deductible (think $5k-10k), but then you also have money that is put into an HSA (Health Savings Account) each month. You can then use the money from that HSA to pay for a visit like this. It can also be applied toward dental, vision, prescriptions, your deductible, etc. Also with the new ACA, even those major medical policies are supposed to cover preventative care like PAP's, Mammograms, checkups for your child, etc. So you would basically be self-insuring without having the penalties or if something major would happen.
I work at an insurance agency that deals mostly with farmers. So they're all pretty much self-employed, and that is the type of policy that works best for someone like that.

Yeah we have a high deductible plan with a $5K ded. and an HSA account that we can deduct all medical expenses on our taxes. It's not much but it helps.

Sisugal · October 2013

Has your deductible for 2013 been satisfied?

vlagrl29 · October 2013

no we never meet our deductible

Wulfgar · October 2013

That is why they are doing this, most individual health care policies are extremely horrible. With ACA, I am not sure if there is any groups out there that pool independent business people so that they can combine good coverage with affordable premiums.

The worse policy I had in years was when I was a temp. Even then I didn't have to worry about pre-existing conditions since I had continuous coverage.

Mom987 · October 2013

Yea I was going to say it might be based in how the Dr. coded i,t rather than just a random sickness.

vlagrl29 · October 2013

Wulfgar said:

That is why they are doing this, most individual health care policies are extremely horrible. With ACA, I am not sure if there is any groups out there that pool independent business people so that they can combine good coverage with affordable premiums.

The worse policy I had in years was when I was a temp. Even then I didn't have to worry about pre-existing conditions since I had continuous coverage.

I've bought individual policies most of my adult life and have never had an issue like this. I'm wondering if its just the company? Either way, my insurance agent said this is very common the first year you are on the policy and that year will be over in Jan. for us.

chicagobride_07 · October 2013

If they won't even pay out for a normal doctor visit I don't think it's worth us even buying health insurance anymore and just offer the doctor cash when we go in.

OP- definitely keep some sort of insurance, if only for emergencies. DH and I are perfectly healthy, yet- in the past 3 years- he's needed an emergency $40,000 gallbladder surgery and I had a totally unexpected complication of my pregnancy which required hospitalized bedrest for me and a NICU stay for our little one. The total bill for that was $390K.

None of this was expected, and we would have been financially devastated if we had no insurance. We have a pretty healthy savings account but medical bills can quickly become astronomical.

vlagrl29 · October 2013

ETA - a customer service rep called me this morning because they found out I wouldn't send my medical records. Apparently they need them or other claims I have may be denied. She told me that they would need medical records even if it was just a cold! I call Bullshit on that. I told her I talked to a manager last week and my doc will be resubmitting the claim for what i really had and that it's not chronic. I asked "you need medical records for a cold?", she said yes and I told her I wasn't comfortable sending them for a cold and if I had to talk to a manager again I would and she stopped pushing it and we ended the call. My daughter has gone in for a cold and they didn't need medical records for that! I've been on individual insurance before and have never dealt with this and what we have is good coverage and a reputable company that I've been on before. SMH

short+sassy · November 2013

Welcome to the joy of insurance companies and their pre-existing condition clauses. Luckily, those are illegal starting next year. I've spent half of my adult life without insurance for my medical condition because of those clauses...that used to be par for the course for almost every medical plan, group or otherwise.

I still remember when I switched jobs. Still had the same insurance company, but different group plan. I called their customer service and explained that. The rep didn't understand and kept snottily telling me I needed my previous insurance company to fax them proof of previous coverage. I finally said, "FINE! what is the number at YOUR company to get proof of coverage. Should I still have them fax it or do you want them to just WALK it down to your office?" OMG, she finally understood, lol. Took less than one minute to look up my previous policy and my 20-minute conversational ordeal finally ended successfully.

Medical insurance companies are vile and pure evil.

Update - Furious at our Insurance Company

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