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Sticking it to the Man at the private medical insurance company

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Message Dominique Lord

Reprint from Open.Salon.

Following my most recent post, I realized that I forgot to discuss two things about the private medical insurance industry in the U.S.

Remember how I said that unless an American is self-employed, they pay half the monthly insurance costs and the other half is paid by their employer? Well, the main role of American private medical insurance companies is to manage this money. That is, to assign where it can be used. They obviously do this for a fee in order to make a profit.

And even though the insurance companies manage the money they get from us, they don't always want to assign the money where we want them to. When this happened to my wife and me, I stumbled on a way out of the problem by accident. I'll get to that a little later.

In the third post, I compared benefits and drawbacks with the health care systems here and in Canada. I also gave an example of a time when our private medical insurance refused to cover a medical expense. To recap, my wife and I decided to go for genetic counseling to ensure that she was not a carrier of a genetic disease I have, since that would give us a one in four chance of passing it on to our children. At that appointment, the genetics counselor told us that there was only one laboratory in the entire U.S. that could test for my specific disease. The problem with that, of course, was that the one laboratory in the entire U.S. was 'out of network' for our insurance company, which meant in that case that we would have been forced to foot the entire bill ourselves. So our counselor kindly offered to write a letter for us pointing out that since we had no choice about where the blood samples were sent, our insurance company should cut us some slack, so to speak. The letter was addressed to the insurance company and attached to our reimbursement form, since we had to pay the bill upfront--a whopping $650.00.

A few weeks went by while we're waiting in comfortable expectation that our insurance company will see reason, and then we got a letter back saying that our claim was rejected because the lab was out of network. Okay, we think, maybe they just didn't get the letter. So we contacted the company by phone to explain our situation. And the minion at the other end of the phone told us, sorry, the laboratory was outside their network.

All right, we figured, time to call in the big guns. We contacted the genetic counselor again. She told us that the 'front line' workers (as in, the ones actually dealing with the irate phone calls) sometimes lack a certain amount of knowledge about these issues and very kindly wrote another letter. This time she sent it directly to the insurance company. My charming and talented wife also wrote a letter, gently reminding the insurance company that the out of network lab was the only one in the United States that could test for this particular genetic disease. She also mentioned that if we hadn't got the testing and our child was sick, it would end up costing the insurance company a hell of a lot more than $650.000. We sent that letter by registered mail.

Another few weeks go by and we received an actual letter--not a statement this time but an actual letter--addressed to me personally. And saying that the claim was still denied.

Now out of options and pretty upset by this turn of events, I casually mentioned what had happened to the Director of Human Resources at the university where I work.

That's when he told me that since medical insurance companies only manage the money the employer and its employees contribute for health care coverage (which I hadn't known), it's the employer that has final say about where the money can and can't be spent.

This had possibilities.

Even better, my colleague said I could ask a special committee, which would include employees of the university as well as some independent medical professionals, to convene and hear my case against my insurance company. He also told me that he himself had sat on this special committee for many years, and that often the individuals were successful in convincing the committee members to pay for their treatment, therefore overruling the insurance company.

Right on, I thought. My wife and I decided to go ahead and ask the special committee to hear our case.

Interestingly enough, about two or three weeks later (oh yes, the timeline spanned months at this point), we received yet another letter from our insurance company, indicating that lo and behold, they agreed to cover the costs associated with the genetic testing. Apparently--get this--despite the three letters explicitly saying so, they had somehow remained completely innocent of the fact that there was only one laboratory in the entire U.S. where the such testing could be performed.

It turns out, when you ask the special committee to convene, the insurance company is also notified that a claim is being disputed. I'm assuming that at that point our insurance company realized that the case was against them and decided to pony up.

The main lesson I learned from this experience--aside from the fact that apparently some of the people at our insurance company can't read--is that if your claim is repeatedly denied, contact your head of the human resources where you work and see whether they can help you. As I mentioned above, in the end, it is your money.

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Dominique is an Associate Professor in the Zachry Department of Civil Engineering at Texas A&M University. His research work aims at reducing the negative effects associated with motor vehicle crashes. When he's not developing mathematical and (more...)
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