when is health insurance coverage not health insurance coverage?

[unblock]

apparently whenever they decide.

my wonderful health insurance company decided, in their infinite wisdom, that i only get 6 migraines per month. my neurologist and i are convinced that i get an average of 24 per month, but what do we know. they denied my request for a "prior authorization" based on nothing more than their desire to pay out less in claims.

so my health insurance company will pay for 6 doses of zomig or generic sumatriptan per month, and the other 18 doses i have to pay out of pocket. since they decided that the additional doses aren't "medically necessary", THE ADDITIONAL EXPENSES DON'T EVEN COUNT TOWARDS MY $4,000 ANNUAL DEDUCTIBLE!

generic sumatriptan costs $220 for 6 doses, so that's about $660 extra per month or $7,920 per year.

so my employer and i pay something like $10,000 per year in annual premiums (which ultimately means i'm being paid that much less), i have a further $4,000 deductible before they pay anything, and i STILL have to pay $7,920 out of pocket!

[PA Democrat]

1. K & R

Health insurance is all about profits, not actual health care. They pay out as little as possible to retain the illusion of providing coverage.

[unblock]

32. the bottom line is that they're in the health coverage DELAY AND DENIAL business

that's their core competency.

[Lydia Leftcoast]

2. THAT is a perfect example of why I am opposed to the private insurance companies

having any role in health care. It is why I am vehemently opposed to the Senate bill.

They second-guess doctors more than any government bureaucracy ever would, and they happily take thousands of dollars of year from the enrolled persons and then ask them to go through a complicated pile of paperwork for the "privilege" of paying thousands of dollars more out of pocket before any coverage kicks in.

What a license to print money!

[lapislzi]

3. When you can't actually use it to obtain medical care.

I have the same problem. My question: what medical school did my insurance company attend? What qualifies them to diagnose my condition and prescribe treatment without ever having seen me?

:argh:

[uponit7771]

4. wow...fuckin...wow...Do you have the ability to get suplemental insurance? Prolly better to pay

...the 1-300 a month than what you're paying now

[unblock]

9. thanks. if all else fails, i will look into that.

[earthboundmisfit]

18. Yup. Insurance to pay for

what insurance won't pay for.

[prairierose]

5. That certainly sounds like...

not health insurance coverage to me. When will we ever be free from these so-called insurance companies who care for nothing but profit? I know there are actually quite a few in Congress who want to change this system for the better but there are still too many in Congress and out who do not have the foggiest idea what is really happening to people. Some probably choose not to believe it in order to salve their conscience for the bribes they take.

[peace13]

6. Have you appealed this decision?

I would have your doctor write a letter to the insurance company. Go at this thing with both barrels and suggest that possibly more expensive evaluations, and procedures could result from their withholding this medication.

My insurance company refused to pay an emergency room bill once because they said it was too high. The emergency room doc had wanted to take me up to a surgery room to finish cleaning a wound that they had been working on for over an hour. I asked them to not do that and said that I would cooperate fully where we were. Long story short when I got the refusal of payment from my insurance company I wrote a letter stating that I had done my best to keep their costs to a minimum and if they wanted my cooperation in the future the bill needed to be paid in full. It worked. They paid it all.

[unblock]

8. i will begin the appeal process, but guess who decides the appeal? the insurance company, of course

if that fails, i can pull a power play. i'm a senior executive at the small company i work at, and once they realize that i can walk 15 feet into the ceo's office and get the entire account yanked, THEN i'll probably get the medical attention i think i'm already paying for.

but most people, of course, don't have anything like that kind of clout, and i might be deluding myself as to how much clout i actually have. hopefully it will not come to that.

AT A MINIMUM, this is a classic delay tactic on their part. even if they approve my appeal, they will have successfully delayed filling my scrip for a month or two, saving them money.

THEY CAN BE JERKS WITH IMPUNITY. there's NO DOWNSIDE for them to try this kind of crap.

[peace13]

14. I hear you! n/t

[Gormy Cuss]

21. Look into filing a complaint with the state insurance dept.

They may not get involved until after your appeal has been denied, but it's worth a shot to see if they can at least put the insurer on notice. Insurance companies count on customers not fighting back.

[PA Democrat]

38. I think someone else mentioned it, but I too suggest going to your state's insurance department

and file a complaint. If you don't get satisfaction from them, contact the state Attorney General's office I think that Connecticut has really cracked down on insurance companies after your AG Richard Blumenthal got involved. Your state's former insurance commissioner, Susan Cogswell, had failed to take timely and meaningful action against a company with a pattern of fraudulently denying coverage. Blumenthal got involved and lit a fire under her. Because of Blumenthal's involvement, the company was also fined.

http://www.ct.gov/ag/cwp/view.asp?A=2341&Q=333840

[unblock]

41. thanks!

[PA Democrat]

42. Good luck!

BTW, as another poster suggested, make sure you copy the insurance company on correspondence to the state's insurance department. I've unfortunately had to go this route, and while it is extremely frustrating, I eventually got my medical bills paid after months of delays and denials.

[truedelphi]

44. Sorry for the hassle that you are going through.

No wonder you are experiencing two dozen migraines a month!

[jtrockville]

7. Bean counters shouldn't be intervening between you and your doc.

Insurance is nothing but a SCAM. For-profit insurance should be eliminated our healh care delivery system.

[undeterred]

10. Yup.

I have frequent migraines too, but no job and no health insurance.

[Cleita]

11. Sue them for racketeering under the RICO act because this kind of

paying out of protection money and getting nothing in return is nothing more than a racket. I don't know if an attorney could make a case but maybe it's worth a try. If Congress won't do anything about these companies, maybe the courts of justice will.

[gkhouston]

12. Greedy unprincipled fuckers. Have you had any luck with preventive medications? n/t

[unblock]

15. tried pretty much everything, without luck.

at best these things work for a month or two before my body adjusts and i'm back to square one.

[gkhouston]

22. You have my deepest and most sincere sympathy.

I was lucky enough to find a preventive med that works. Before that, it was just awful.

[hunter]

13. My insurance company sends me letters suggesting I change my meds...

... usually about the same time my insanely high deductible runs out.

Mind you, I've tried the "$4.00 pharmacy" meds they suggest in agreement with me, my doctor and my therapist, but it didn't work out.

I think inexpensive generic meds are underutilized, that doctors too often prescribe more expensive meds, and that some generics actually work better than the much more expensive brand name meds. But that's not always the case, and it's really between the doctor and their patient.

I would be quite pleased to see the health insurance industry as we know it put out of business by a national single payer plan.

[dkf]

16. And congress decided to permantly base our health care on these scumbags.

Rahms brother wants to turn Medicare private and give us all this travesty.

This hcr bill sucks. It will condemn everyone to this treatment for eternity. Nothing in the hcr bill does anything for this mistreatment by people who get bonuses for cutting you off from your medication.

[vicdoc]

17. Sorry to hear that...

I'm a Doctor, used to accept health insurance and Medicare, Medicaid. I went to bat for my patients many times to get surgical procedures approved. Sometimes I was successful, sometimes not. You have to look at your policy for the fine print which excludes and limits what they will do for you. Most of the time it is obscure or located in a manual somewhere you cannot easily find. It also changes year to year. You can appeal the decision your insurance company has made, and you might be surprised at the outcome. Persistence definitely pays, I have found, particularly if your Doctor is willing to write a supporting letter for you. The appeal process goes up a level to someone who actually evaluates your situation, not a CSR who just looks at the rule book and says "Sorry".

Insurance companies are in there to keep expenses low (you are an expense, a "loss" account).
It would be populist for me to say they are evil but they are not. They are in business. If they paid your migraine costs to the full extent, and the expenses of the other 50,000 people in your plan, your premiums would skyrocket. You add up all the expenses, add the millions in salaries, the big shiny building and 4% shareholder profit, divide it by 50,000 (or how ever many of you there are in the plan) and there's your $10,000 premium. And of course there's the fraud, waste and abuse.

As an aside, the Federal government run Medicare was horrible and State run Medicaid even worse compared to the for-profit insurance plans as far as how responsive they were and their re-imbursement for my services. I went back and forth with them for low re-imbursement and the 2 month wait for my fees. We had to deal with them through their contractor (EDS, I think) is some other state. They still owe me $1000 for procedures I did just before I quit them and I finally gave up trying to get it after 4 or 5 months.
And before you go after me as a rich Doctor, I went out of business (couldn't feed my family or pay my bills) because the re-imbursement fell steadily over the years. My before tax income in my last year was $30k, and I averaged something like $75k over the 18 years I took insurance. I only work for cash, credit now, and negotiate directly with my patients.

Here's one story for you (I have many since I have been in practice for so long): I repaired a large, nasty sacral pressure sore about the size of your hand on an unfortunate lady with Multiple Sclerosis some 10 years ago and after several weeks in the hospital she was ready to go home, but she needed a special air flotation bed to prevent the sore from recurring since she was all but paralysed. We went to Medicare to see if they could buy one for her since she could not afford it. They said they would rent one for her, but not buy one. It cost $900 (!) a month to rent it and they would pay for it for something like 14 months. You do the math: that's about $12,000. A new bed to buy was something like $6000 to $9000, and a used or last years model (new) was $4500. But they would not budge, they were so stubborn. I don't know the reasoning, I don't think there was a reason. (Maybe it's different now?). So the family (Medicare) rented the bed for the 14 months. Medicare stopped paying. The family told me the rental company never picked the bed back up! Tax dollars paid $12,000 for something that could have been bought for $4500. What a waste! Multiply that by 1,000,000 times a year and you can see why Medicare costs so much and is going to go under in less than 7 years. How much was I paid? $1200 for the 3 hour operation, 20 visits to see her at the hospital and all the followup at the office for 90 days after the surgery.

[Lydia Leftcoast]

19. I agree that there are some serious problems

My own brother quit accepting Medicare because of nonsense like that. Also, the rules were so complex that it was easy to break them unknowingly, and getting a few letters accusing him of deliberate fraud for not following rule 1.1.3.5. on p. 500 (or whatever it really was) spooked him.

The idea of Medicare for all sounds attractive, but we need to fix the system before applying it to everyone.

[unblock]

23. i don't begrudge them trying to shift me from (brand) zomig to (generic) sumatriptan

now that sumatriptan is available as a generic. what i do mind is the economic frictions they introduce (the hurdles they make you jump through provide no real economic benefit to anyone in the resource allocation sense, they only shift dollars from me to them. the "free market" is supposed to reduce paperwork and other economic frictions, not create them.

but not only did they do that (zomig is went from tier 2, deductible didn't apply to tier 3, deductible applies; and, generic sumatriptan is tier 1, deductible applies) but this limiting me to 6 doses is just ridiculous.

ESPECIALLY BECAUSE THEY APPROVED ME FOR THIS LAST YEAR.

i guess they must think i was cured or something.

[Greyhound]

20. K&R. I'm so sorry for your situation, I'm all too familiar with how these scumbags work.

Unfortunately, "our leadership" decided your life is meaningless, except as a corporate revenue stream.
:kick: & R

[Vinca]

24. Call the media. That seems to be the only thing that ever works

for people to get their insurance to cover them. Big insurance hates bad publicity. I'd bitch to the insurance commissioner of your state as well.

[unblock]

25. unfortunately, my state is connecticut.

i'm sure the insurance commissioner is bought and paid for.

[REACTIVATED IN CT]

27. He is a Rell appointee, but don't let that stop you from

flooding his office with paper.

[REACTIVATED IN CT]

28. One other item of interest in CT, the insurance companies

have to pay interest to the individual when they take too long to pay a claim. Fight back !

[njlib]

37. That could very well be

but the media would jump at your story! Definitely start the appeals process, but it wouldn't hurt to contact the media in the meantime. There's a lot of anger towards the insurance companies and their quest for ever increasing profits and THAT'S what the media would want to exploit for ratings. It's worth a try because you've got nothing to lose...and it might even inspire other people who are getting screwed to do the same thing!

[REACTIVATED IN CT]

26. Appeal the decision. Keep pushing back !

Look at your plan documents for the appeal process and follow it. Don't let the beancounters win.


eta - I see that you are also in CT. Be sure to cc the Insurance Commissioner on all correspondence. Also keep the CT Healthcare Advocate in the loop.

http://www.ct.gov/oha/cwp/view.asp?a=2265&q=299842&ohaNav=|

[unblock]

29. thanks!

[elehhhhna]

30. Tell them in writing you assume they will pay for your emergency room

visits when you have no meds.

[unblock]

31. excellent point!

once i max out my $4,000 deductible, it's all on them.

why should i pay for meds at a pharmacy outside of pocket when i can get meds at the e.r. that they will cover?

[mdmc]

33. another awful story from the insured without treatment

Soon there will be 38 million more of us. Mission Accomplished.

[Left coast liberal]

34. They are parasites feasting of us. NT

[autorank]

35. $1800 a month

You think I'm pissed off?

[unblock]

36. yikes!

[autorank]

43. If you're self employed ...

Trapped - could save a lot but can't leave the current company due to my wife's pre-existing, which are not earth shattering but just enough. The current company is in NY State. If I were there, I could lower it, but since I'm "out of state," I have no options to modify -- unless i reapply for a new family plan. You can imagine how thrilled I am to hear that adults get to wait 4 more years for the pre-existing conditions clause to kick in. There's worse.

Here's the scam on the self employed. If your employer pays, you pay from 15% to 30% for health insurance. Your employer pays the rest. If you're self employed, you pay the whole nine yards.

The blue line is premiums only. The low premium states, however, compensate for this with high deductibles. So a policy in Utah, a low premium state, has a $16,000 deductible and, with premiums, costs more than a high premium state, Massachusetts.


From: Screwing the Self Employed Out of Health Insurance
http://www.smirkingchimp.com/thread/23407

Long answer to a "Yikes" but

[Dappleganger]

39. As a fellow migraine sufferer, I'm sorry to hear this.

Mine were so common that the doctor put me on a beta blocker which has helped significantly (that was over 10 years ago). That pretty much let me have my life back.

:hug:

[unblock]

40. beta blockers do help with a very minor tremor i have (and couldn't care less about)

but they don't do squat for my migraines.

it's the triptan meds that gave me my life back, and my insurance company wants to take that away.

you know, i think they want me to switch to narcotics, they're much cheaper (and far less effective).

[TexasObserver]

45. Any time the insurer writes a letter saying it is not covered.

Which is pretty much any time they can come up with any rationale to spend more money than is absolutely necessary. Even if a person has great coverage, if they become a major cost to their insurer, you'd better believe they're reviewing records and patient history to see if they can kick the claim as not covered for some reason.

It's not as if there is a government agency waiting to kick their ass for reneging on their coverage.

[warren pease]

46. As I wrote several months ago...

Medical insurance has nothing whatsoever to do with health care except in the twisted minds of Chicago School libertarian fanatics and profiteering free market pitchmen. Break that nonsensical, artificial link, dump the idea of for-profit medicine entirely, replace it with a single-payer, universal-access system and spread the risk over the entire population in the form of a modest, progressive tax.


Screed from my journal

[eridani]

47. It's a completely whimsical decision

And Congress wants force us to have them between us and our doctors.