Insurance=highway robbers

[mattwisconsin]

Sorry but I needed to vent.

So I am one week out from surgery right now. I have spent the last few months dealing with all sorts of issues. I have spent a lot of my time getting my health insurance in order and getting a waiver for the pre-existing condition clause. As far as I could tell my insurance was pretty good, until someone from the insurance company pointed out the following line:

"EXCLUSIONS
No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from;
b) treatment, services, or supplies for, at, or related to: . . .

Surgical treatment of congenital conditions, except as specifically provided for Newborn or adopted Infants;"

Now I am in the position that I need to have the doctors list my diagnosis for surgery as specifically linked to the endocarditis and to hope that this is not too linked to my congenital condition. However, they won't work on processing the claim until after the procedure. So now I get to go into surgery with a ? as to whether it will be covered by my insurance.

I have been fighting with insurance companies for the last 10 years being cursed with this pre-existing condition and I have to ask if and when they will ever just cover it.

Has anyone else found that their insurance just says, "oh by the way, we don't cover surgery."

 

[dick0236]

Sorry but I needed to vent.

"EXCLUSIONS
No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from;
b) treatment, services, or supplies for, at, or related to: . . .

Surgical treatment of congenital conditions, except as specifically provided for Newborn or adopted Infants;"

It would appear that the insurance co. included this exclusion based on your heart procedures at 3 and 13. They most likely got this info off your application or from some information developed during the underwriting. You should have been advised of this exclusion when the policy was delivered to you which would have allowed you to accept or reject the policy because of the exclusion. If your needed procedure is due to Endocarditis and not related to your congenital condition, have your doctor work with you in dealing with the insurance co. You might also check with your state insurance dept to see if there are any time limits, etc. on such exclusions. If nothing else works, have an attorney look at the policy for any potential "loop-holes"

 

[Philip B]

Insurance

Insurance

Hi Matt,

You're not the first to face dealing with insurance issues. My problems never got to the point of "gee, we don't cover surgical procedures" but I did have an issue when my company attempted to label my surgery "elective". I guess it was initially viewed as elective because my bad aortic valve was still working and my 5.8 cm aortic aneurysm had not blown-up yet. My policy doesn't cover elective surgeries.

Both my cardiologist and surgeon had to make the case that my surgery was not elective. My insurance company did pick up a large chunk of the bill, but by the time I finished making co-pays and doing the out-of-pocket stuff, my savings account was empty and I am still paying some expenses off. It pretty much wiped us out financially...who needs retirement anyway?

My wife and I had a rather "dark" conversation when we initially encountered problems with our insurance company...do we go ahead with an expensive life-saving surgery if the coverage wasn't there, or take a chance that the aneurysm and valve problem could wait? In the end, we decided to move forward with the surgery and that we would worry about how to pay for it later.

I really can't blame the insurance company. The school district I work for purchased a product from the company and it's unfair to expect the company to not really take a hard look at whether I was eligible for coverage or not. If anything, I blame my employers for not providing me with better insurance coverage.

-Philip

 

[mattwisconsin]

It is University insurance. I am a graduate student at Ohio State and so I am pretty sure it is just the general comprehensive insurance there. I think I am leaning toward just not worrying about it and having the surgery and dealing with the fallout afterward.

 

[Bina]

I can't imagine going through all that hassle. I mean really, who on God's green earth would ever classify OHS as elective surgery?
"Well, I'm going to get my crooked nose straightened out, I may as well throw in a high risk cardiac surgery while I'm at it."
DUH

 

[Lynlw]

I can't imagine going through all that hassle. I mean really, who on God's green earth would ever classify OHS as elective surgery?
"Well, I'm going to get my crooked nose straightened out, I may as well throw in a high risk cardiac surgery while I'm at it."
DUH

As far as I know "technically" all surgeries that you plan ahead for and aren't rushed from the ER (or cath lab) are considerred "elective) I always thought it was pretty stupid. Believe me IF I had a choice I wouldn't have elected to have my 10 day old baby have heart surgery, altho to their, point, I did choose that over the option on not doing anything.

 

[Lynlw]

Matt , have you ever had a lapse in insurance? IF NOT than I believe they can't use the preexisting clause, only if you let insurance lapse.

 

[lilteach3234]

It is University insurance. I am a graduate student at Ohio State and so I am pretty sure it is just the general comprehensive insurance there. I think I am leaning toward just not worrying about it and having the surgery and dealing with the fallout afterward.

Matt,

Get yourself taken care of first and get your life back to its fullest. I worried about the costs before going in even though I am covered by two Blue Cross/Blue Shield policies and a military policy. I luckily had taken out a nice portion of flex plan money for this year so this took care of up front costs.

In my opinion....I will pay $5 or $10 per month until each bill gets paid. You can't squeeze blood from a turnip.

 

[kfay]

Matt, First of all, I would not leave it until after surgery to see if the insurance is going to pay for it, unless you can afford to pay for it out of pocket. I can't believe that the Dr. and hospital would even be willing to go ahead without prior approval from the insurance company. I had to sign paper work that stated that I understood I had to pay any amount that the insurance company didn't pay. Has this insurance company been paying for all of your pre-surgery testing and Dr. appts.?

Secondly, speaking as another Congenital Heart person, there is not a health insurance company around who will insure my heart condition unless I "sneak" in under a group plan.

I understand your frustration with all of this, especially this close to your surgery. It is certainly not something you want to have to deal with at this stage of the game. I hope it works out that they cover it for you.

Best of luck next week.

Kim

 

[Lisa in Katy]

Matt --- You have what is considered a limited policy. My guess is that it is very cheap, perhaps included in your tuition and fees? However, you can ask the insurance company for a predetermination. Both your physician and the hospital should be familiar with how these work as they are done frequently.

Philip --- I think this has been discussed in another thread, but I'll try to address your confusion. Most insurance policies refer to two types of surgery - emergent and elective. There are a few that also refer to a third type - urgent - but most include urgent in elective. Most, but not all, valve replacements are considered urgent, but not emergent. Unless it is an emergency, i.e., gunshot, car wreck, heart attack, ruptured appendix, accidentally amputated limb, or other similar thing that is going to result in imminent death without surgery, it is elective. If you have the convenience of being able to plan the surgery ahead of time, and you have the choice to not have the surgery, it is elective. It does not mean it's not necessary, it just means that delaying it for some period of time (could be a day, could be a year) probably will not affect the outcome. Most cancer surgery, hip replacement, cataract surgery, most heart surgery, facelifts, breast implants, tattoo removal are all considered elective. There is a recent story on here of a person who "elected" not to have surgery, so you see where the definition comes from.

I can't imagine anyone selling or purchasing an insurance policy that states that it doesn't cover elective surgeries, unless it is simply a catastrophic policy, which most group coverage is not. Obviously they were trying to save a dime. In Texas, it is illegal for group coverage to not cover elective surgery if it is medically necessary. Most policies exclude cosmetic surgery, but include some non-medically necessary surgeries, e.g., vasectomy, circumcision, and tubal ligation to name a few.

 

[Philip B]

Coverage

Coverage

I'm sure this comment will draw some irritated responses and may get me labeled as a commie, but I'd sure like to see quality health care in the US become a right. Unfortunately, it seems that access to quality health care is often related to one's ability to pay or willingness to make payments.

Yeah, I've heard all the conservative commentary about how bad the socialized medicine systems in Canada and Great Britian are. I don't know much about those systems or how well those systems actually work...I just wish we could come up with something that would work better for everybody in the US. I know people who will never be able to pay all their medical bills.

Good luck with your insurance issues.

-Philip

 

[mattwisconsin]

Well I was told that the endocarditis will be covered and so the surgery is approved but they can't make any promises until afterwards so if they start doing a bunch of work in there that is considered not associated with the endocarditis the insurance company may choose not to cover it. I think I have decided just to fight that battle when it comes up afterward. But the predetermination makes some sense.

On the commie issue it is a slippery slope. I have heard both horror stories and huge successes in both Canada (my girlfriend used to work up there) and Greece where friends of mine have lived for decades and had successful bypass surgeries for next to nothing. However, one of the main hospitals now has a 100% infection rate with things like staph when you go in for treatment so there are good and bad stories.

Also these new adds for http://cprights.org are dangerous. Rick Scott, innocent until proven guilty, but pretty much is guilty of ripping off the government and medicare.
http://www.washingtonmonthly.com/archives/individual/2009_04/017563.php

So there has to be a better solution, but I certainly don't have it. I am hopeful that I will see it in my lifetime and I think we may be working towards it. Unfortunately, I think it is years away.

Sorry for latching onto the political bent here.

 

[Lisa in Katy]

Philip - The problem isn't really access to quality care. Hospitals can't turn away patients who are in true emergency situations, and most hospitals do plenty of charity care. There are also designated "charity" hospitals. I think the official name in most states is safety net facilities. All of the staff and physicians at these facilities must meet the same criteria as other facilities. The same is true for outpatient services - there are plenty of free clinics. In Houston, there are 3 hospitals, 14 community clinics, 8 school based clinics, and a dialysis center that are funded by my tax dollars. They even have a program to provide healthcare to the large homeless population that we have.

 

[Lisa in Katy]

Here is a picture of Ben Taub Hospital, the largest of the facilities in the Harris County Hospital District taxing authority - hardly looks like a place that gives inferior care!

 

[Philip B]

Confusion?

Confusion?

No confusion here...my insurance company didn't want to pickup any of the tab for my surgery because they initially considered it elective. How my surgeon and cardiologist made the case to get it covered, I really have no details about. Those guys dealt with my coverage problem. I do know that it was a relief when they worked their magic to get a chunk of it covered.

I'm also unaware of any medical facilities that would do the freebie surgery thing in Colorado. That's not to say those kinds of facilities don't exist. As an individual who is employed and would be considered by others to make a decent salary, I doubt I would personally qualify for free medical care anyway. Like others with lousy insurance, I'm one of those folks who gets to make payments.

It's not a good sign when you're meeting with the business office folks in the cardiologist's and surgeon's offices and they say something along the lines of, "Oh, crap! You've got that insurance company! We always have problems with that company." Somewhere along the line you get the feeling that someone made a poor choice and things may not be looking so good.

Like it or not, there are good companies and good policies out there as well as some bad ones. Hopefully, others will fare better than I did. We thought we had better insurance than we actually did. In fairness to my employers, I think our business manager thought the district's policy was better than it was. I was the district's first employee with a pre-existing congenital valve issue who needed surgery. The district does have excellent life insurance coverage for administrators. My wife would have done okay if she could've cashed in...hmmmm...I guess she still could.

I don't have any answers, but I do wish we had some kind of system (other than better insurance) that would take care of this high dollar medical stuff without devasting folks financially.

Matt, I'm glad your situation appears to be working out.

Lisa, I appreciate your perspective from the insurance company side of things. Like I noted in an earlier post, my district bought what it bought and it would be unfair to expect the insurance company to cover expenses which are not covered in the policy.

-Philip

 

[Lisa in Katy]

Denver Health Pavilion for Women and Children is a safety-net facility. In 2007, Denver Health also had 8 family clinics and 12 school-based clinics in Denver. University of Colorado Hospitals (more than one campus) and Memorial Hospital in Colorado Springs are other safety-net facilities. There are probably others, but I stopped looking.

Also, the confusion seemed to lie in why they call valve replacement surgery elective. The answer is "because it is." My guess is that your doctor wrote a letter to classify your surgery as emergent, which may or may not have been true, but it worked. You're right. Your insurance policy is apparently terrible. If they don't cover elective surgery, they really don't cover anything. It wouldn't only apply to those with pre-existing or congenital issues. It would apply to everyone. As I said before, hip replacement, cancer surgery, cataract surgery, etc. are all considered elective, so I assume this policy doesn't cover those? Even most C-Sections are considered elective! Tell the person who chose it that if it seems too good to be true, it probably is.