Health Insurance

[Guest Phyllis]

I have a question I need advice on. My health insurance company (I don't know whether or not to say their name) is delaying claims and pulling other stuff on me. My throat surgeon called me two weeks ago to ask if I wanted to be declared partially disabled or fully disabled. At that time I had not started the application for social security disability. I went to pick up the form from my doctor to discover it was from my health insurance provider. I have been very careful to maintain my employment at an average of 31/hrs./wk. since all of this happened. At one point I did have to go on COBRA insurance (Boy, that COBRA need to be revamped so people can actually afford the d---! stuff.). My co-workers have also donated benefit time so I could continue my insurance.

I decided then that I did need to file for social security because I cannot afford to be without insurance. People with a life threatening disease should not have to worry about this kind of b______! Now I just feel under pressure to get this taken care of especially if I am going to get to get the procedures I want. Then I get a letter from the insurance carrier that they were delaying the claim for my weekly blood tests. All of my hosptials are basically carrying me now since I can't pay them what I owe them. My doctors are appalled when I told them what these a____h____! were doing. Pardon my french. This is not great insurance anyway.

Then they told me that the Univ. of Chicago where I practically live would not negotitate with them so they dropped them as a member of the providers' network so I have to pick up even more of these costs. U of C said it wasn't them it was the insurance company. Then I start seeing all of these ads for this bunch of weasels on the tv talking about how affordable, compassionate, blah blah. Can they do these things? Can they send forms out without my knowing? What about HIPA? Thanks for letting me vent. Sorry for the long post. I am just really upset.

[Elaine]

Phylis

SOrry to hear of your insurance troubles. I have them too and it is so stressful, mind boggling, maddening and sometimes it makes me feel hopeless, but don't let it do that.....

I think it is ok to name names as long as you are stating facts. I worked as a journalist and know that one of the main ways to put pressure on wrongdoing is to go public.

I don't really understand what is happening in your situation from what you have written here. Do you have a case manager through your insurance? I learned the other day from some website or another that they are supposed to be patient advocates --ha. Mine is HMO advocate, when I can reach him.

Make waves and take Fay A.'s advice.

She knows.

Elaine

[Frank Lamb]

Phylis, Elaine is right it is very stressful and maddening to have ins. trouble.When I was diag. I was just starting new job w/no insurance at all.I still have not been able to get me or my wife insured (not enough $$)

Fortunately I 've had everything done thru the VA as I'm a disabled veteran.However they don't cover my wife.They did a good job so far but there are lots of faults w/ the VA system.(mostly underfunded and understaffed as everywhere else around here)Please hang in there and don't weaken as they will try to wear you down.Good luck and kick their butts.

[karen335]

Phyliss,

I don't think it is legal for them to request personal information about you unless you have signed paperwork (HIPPA FORM) authorizing a doctor, hospital and etc. to release this to them. I had a situation yesterday with my Primary Care doctor. They received authorization from the middle man (IPA) saying I could have treatment at the City of Hope next week. I asked the gal at my Primary Care doctor's office if she could fax me a copy and she said NO. I would have to go in and get a copy. This was due to the HIPPA law. If they are getting this info without your authorization, I would think you would have a lawsuit aginst the insurance. This does not sound legal to me, this is only my opinion...

I would check it out. Good luck...

Blessings and prayers,

Karen

[Guest bean_si (Not Active)]

Phyllis, Sorry to hear you're going through the same thing. I was virtually forced to retire though I can't collect yet other than taking the lump sum with a 30% penalty.

My insurance CONTINUALLY denies my chemo claims - thousands of dollars - even though they gave me the refferal. Of the three chemo guys, one is PPO. I go to the HMO. I talked to the office and they said they submit it under HMO doctor. Then the insurance comes by & says it can't pay it because it's under the PPO doctor's name. THEY had to do that.

I went to ER twice. These were denied. I had to fight to get it paid even the reasons were ULTRA valid. Tests are denied saying they were put under wrong social security so I run around contacting doctors, clinics, to resubmit while BS insurance holds on to money and interest it's earning from same.

It goes on and on and on. Most of my day is fighting them. My quality of life is deeply impinged by this spineless maneouevering. Just to get a 2nd opinion at MD Anderson - not treatment - my chemo doctor was supposed to sign a Medically Necessary. Bull. It's state (federal?) law that you can go to ER without primary's referral & can be treated if it's serious without referral. I also think there's a law about second opinion and treatments not available in your area but I can't find any.

I spent hours sorting through all this. I really think there's something illegal going on here but who do I or you turn to? Forget the Oncology nurse - intermediary - you don't even want to hear about that. Mine knew EVERYTHING about me before I had even talked to her, mostly in terms of how much the insurance company had spent on me. The second call from her when I was still grappling with the disease, all she wanted to know was if I'd thought about End of Life and what to do. I was fighting for my life - all she seemed to care about was arranging hospice and End of Life and making sure I know they didn't pay for alternative medicine. Anyone got ideas?

As to the Social Security, I was told that you can get SS payments after being disabled for five months but you can't get medicare until two years after you started receiving disability. I got that info from the SS office.

I know this isn't helpful but I thought you'd like to know others are going through the same thing. If I find anything that will help you, I'll let you know.

As I've mentioned on this board before, there is deep hurt in knowing that your "cure" may lie in how much money you can contirbute to your care. For me, after being forced to retire and paying out $350/mo for retiree insurance (COBRA) you're lucky to eat. I'm sorry you're going through the same thing.

[mhutch1366]

I wish I knew something to help.

Apparently my oncologist's group had just come victorious from the field of battle with my health insurance provider when I was diagnosed, because the doctor smiled and said something about, oh, they won't give you any trouble NOW, because we've just been through all of this with them.

Everyone cooperated -- all the doctors both private and NIH, and when it came to getting the hospital bed and o2 tanks at home same day as requested asking from NIH to the provider, my primary and NIH doctors were in complete synchronicity. Make it so, number one!! (and it was done).

I recognize life is unequal. I lost my friend Fran Patrowicz, who died last spring of lung cancer, because she was diagnosed as she started a new job just before insurance kicked in, and couldn't privately afford the follow up chemo. That lousy 15000 $ would have saved her life, She was only 55 or so....

pardon the rant.

BOTTOM LINE: It isn't equal and it isn't FAIR. Unequal access to medically necessary treatment HAS TO STOP!

Even Happy the Bassett (<<) I am certain would agree.

Prayers....

MaryAnn

PS bean_si, I had da*^ed well better drop in my tracks, because I'm going to have to work until age 75 at least if I want to be able to afford insurance when I retire. Aw, I didn't want to retire anyway, wouldn't know what to do with self....

[MO_Sugar]

EVERY state has an Insurance Commissioner, usually located near the state capitol. Contact them and have them check in to a suspected case of fraud OR TELL your insurance carrier that is your next step. I know in MO they have taken a couple of insurance companies to task and ended up getting payments.

God Bless,

MO

[Snowflake]

I worked for a doctor and did his billing. (As a disclaimer, let me also add that I no longer work for said doctor because I disagreed with his ethics due to the "nature" of his practice and the fees he would charge people who were mentally incapacitated and couldn't REFUSE his "counsel" for his "counsel"..)

ANYHOW, bills were submitted to insurance companies and coded (now this doctor was a "specialist" and only worked on referrals). Insurance companies would send them back as the wrong code...resubmit...something else wrong on the form, etc. This took MONTHS...

And then, there was a patient that had received insurance okay and paid for all of her appointments on first billing with her credit card believing that she would see money back when the insurance paid their part.... Well, dear doctor didn't tell patient that the insurance only covered HER INITIAL INTERVIEW! NOT the twelve follow-up sessions...and of course, he rendered "service" and she paid for it - no refund.

The patient's insurance was through her husband who was a union worker for a big company. The union steward called and tried to work out what was going on - THIS is how I discovered that the insurance HAD said ONE visit and it was PLAINLY written in her chart! She went ahead with more and had signed that she was responsible - not a damn thing anyone could legally do to get her any money in return...

And me? I quit...gave him four hour's notice - on a Friday. I had a new job on Monday....

I lost my moral of the story somewhere... I think where I was going was that the company that gives you this insurance (well, not "gives" but helps you pay for) should have someone that can pull out bigger guns and work with the insurance company and/or doctors. If you think there's fraud, push that button, work that side of the street. If you think it's just someone dragging their heels, remember that EVERYONE has someone to answer to and start working up that ladder! Not happy? Ask to speak to a supervisor - get the supervisors name and extension...and if you aren't happy, go up another step... Take notes, keep a detailed notebook with who you talk to and when, and a little bit on what was discussed, new names/numbers to contact, etc. Stay organized, it may become a legal document...

Good luck!

Becky

[Guest Phyllis]

Thank you everyone. I hate insurance companies. I think I will do what Mo suggested first and call the Insurance Commission. My employer says they don't have anything to do with this, but they are not being strong advocates. I think they did something illegal too with the disabilty form going behind my back. There was another form addressing a delay in paying a claim without more info, but they sent me a copy of that. Therefore, this other form they must not have wanted me to find out about. We should just have a class action suit against insurance companies in general.