Insurance Nightmares

[chaimFL]

We have all had our share of Insurance nightmares....here's mine:

When my wife was pregnant with our now 2 year old son, she was very ill. I don't mean the usual morning sickness, I mean hyperemisis, which is a condition that very few women suffer during pregnancy that is very severe nausea and vomitting all day and all night. At the time I was in Law School and had insurance via my school. I called the insurance company to get a referral to an OBGYN (we had just found out that she was pregnant) and they told me to see the school insurance people to get a referral. I went to the school and they gave me a list of doctors to choose from. I made my selection based on a referral from a doctor friend who I showed the list to and made the apointment for the next morning. The doctor took one look at my wife and admitted her to the hospital.

To make a long story short, she spent an entire month in the hospital with all kinds of tubes and things to keep the nausea down and the food intake up. About halfway through the hospital stay the doctor and hospital realized that our insurance no longer had them as "in-network," but there was nothing we could do until she was feeling better. The list that my school showed me was old and outdated.

After my wife got out of the hospital we haggled with the insurance to cover as much as they would, which turned out to be almost nothing and we got slapped with over $40,000 to pay out of pocket.

We appealed and appealed to no avail and ended up just paying the bills as they came. Turns out it's the patients job to get the most current insurance data possible and not the insurance company's or the school's responsability.

Now I get referrals from insurance companies web page because it's the most current.

[tvcats]

That is just sad. Insurance companies infuriate me. It's almost as if they're working against us instead of for us. OK, I know it boils down to "the money". But what's the point in paying insurance premiums (whether by us or through our employers) if we can't benefit from it?
In the past few years my insurance company coughBlueCrossBlueShieldcough has kicked my choice of docs out of network. The first time the insurance company did let me know. This last time, my doc did. I still haven't heard from the insurance folks over this yet.
The point of my nightmare is that I live in a very rural community with a limited amount of docs available. If they keep kicking them out at this rate there won't be any left to choose from. And the ones that are left aren't worth seeing. It's a hardship on me financially and time-wise to travel to go to a doc, especially for something like a simple problem (ie: sinusitis, etc).
I know my situation is relatively minor to your story, but I just had to vent a little.

[beladonna]

Hi TV,
I dont know how far you have to drive, but with PPO's and HMO's, if there is not an in network provider in a certain radius..ie 30-50 miles(depending on carrier), they are supposed to pay as in network to the provider you do see.

If they keep bumping them out of the area, they should have to pay in network anyway. I would try and find out their criteria on that issue.

And Chaim made a valid point of the patients responsibility to find out who is in the network. You would think the Doc you are seeing would know, but sometimes it falls through the cracks as it did in Chaims case. That was a very major and expensive mistake the school made. But it does not matter in the end. What matters is that you and your loved ones are taken care of.

I look at their website as well, but depending on when they update it, I dont fully depend on that either. I always give my carrier a call to make sure. And document a name. Most of their calls are recorded in case of a dispute.

[Syli]

That's awful. As you basically say, it's up to us to keep things organized and moving - the people we think are supposed to do it for us are too busy and/or don't care.

Keep me in your thoughts. I go before a Grievance panel tomorrow afternoon to review the denial on my Enbrel. I was allowed to send additional documents so sent pictures and got copies of everything the PCP & Derm sent for me. It was quite surprising to learn the letter sent by my PCP had an error in it that might blow my chance and she sent no pt notes to support the case either. The person I spoke with this morning who promised to send everything left for the day with no word to co-workers on how to keep my ball rolling. Had to start all over at 4:30pm and am hoping I have what i need before the review tomorrow.

~Syli

[Chikara]

Chaim, I noticed that you're from Florida, may I ask which school that you attend? The office that I work in pays the claims for the UF student insurance. I work with UF students on a very occasional basis but I may be able to offer a few answers. I can't discuss your wife's condition on these message boards, however, it violates federal law.

Usually with the policies through the universities, it's not the insurance company that writes the policy. The school's student government writes it. I know I sound like I'm defending all insurance companies because I work for one....but I've seen two different student policies written out on paper (domestic and international policies from the same school) and they can be very confusing.

Although it is the policyholder's responsibility to get all provider (doctors) information, if the student healthcare center had a list of in-network docs, then why wouldn't they have an updated list? The school should've provided them with a list.

I completely disagree with your entire situation. I don't think it's fair that you and your wife were slammed with such an outrageous bill, especially an entire month after the charges were incurred to begin with.