Dealing with an insurance company

When I had my spondy surgery I was covered by Blue Cross/Blue Shield and while they were not the greatest insurance company I have had they were prompt in their payments to the doctors and hospital. It was decent coverage with excellent an prescription plan but over all I would have to say my time with Met Life was bliss.

I say that BC/BS was not the greatest and in fact I used to think they were the worst but that was before we switched to Cigna. When my wife lost her job we lost our insurance through BC/BS after we could no longer afford the almost $1000 monthly premium through COBRA. We then spent about 1 year without insurance for my wife or myself. We were able to continue the boys coverage throughout the state with decent premiums (not free). When she was hired by her new employer and finished the wit period we were able to get coverage for all of us through CIGNA and for what I thought was very reasonable rates. Since she works for a national chain restaurant they got a great deal for having such a large group.

Anyway, since being picked up by CIGNA I fully understand that anything relating to my spondy is pre-existing and that by the contract it will remain so for 1 year from the date we started. Not a big deal as I do not see the doc for that anymore as the surgery fixed it.

However since being on CIGNA I was diagnosed with the arachnoiditis and it has been an insurance nightmare. They have denied all but a few claims to my doc and ALL to the hospital for x-rays, CT Scans and MRI's that I have had done. The total is just over $20K that all these people are know coming after me for. While we have done our best to pat these bills most of the companies/hospitals do not take kindly to the payment plan, they want it all.

I have spent many hours on hold listening to crappy music while talking to the people at CIGNA about this and trying to explain what is going on. I finally got through to them with the help of my primary care doctor. He sent them a letter explaining that my arachnoiditis was not pre-existing and that all my visits to him since being covered by CIGNA have been for this and not the spondy. The lady I spoke with was very pleasant and found in the pile of papers they have on me that my doctor has indeed told them I am not pre-existing. She then sent that along with all the claims denied as pre-existing back to the proper department for processing. She said the letter should fix a lot of the problems and the doctors who have filed claims should get their checks within 15 business days. I took down her name and all the info she gave me and I will call them back after the holidays to double check. If what she said is true then I should be getting some money I have paid to the doctors above and beyond my co-pay ($15 per visit) which should be a tidy little check.

Moral here? Persistence pays off. This has all reminded me of the movie/book The Rainmaker by John Grisham. It is a story of a poor family in the south who pays the premiums for a policy and then when the son is diagnosed and in need of care for leukemia they deny all the claims. The boy dies without the care he needs, although had he received it in time his chances for survival would have been 90%.

Anyway, I know the insurance companies are in business to make money for their shareholders and I do not begrudge them that. However to deny claims persistently in the hopes that the insured just say oh well and pay the fees themselves is perverse. If BC/BS had done this to me I would either not have been able to have the surgery or come up with the close to $400K that it cost over the year of care(includes about $200K for surgery & hospital stay). Our premiums are paid on time all the time and we do not ask for anything above and beyond the policies coverage, I would expect them to honor the policy from their end and pay the agreed amounts to the doctors.

Through all of this dealing with insurance companies I found out something very interesting. in order for the insurance company to agree to cover patients through that doctor or hospital, the doctor/hospital must agree to a standard payment for services. These payments differ from doctor to doctor. While BC/BC might pay $1,000 for a head CT CIGNA may only pay $600. Meanwhile if you the patient did this without insurance you would pay what the hospital really bills which will be MUCH more then what the insurance companies pay. BC/BC paid $88K for my surgery (split between the doctors service and the OR fees) by itself and I asked my neurosurgeon at that time if I had the surgery without insurance how much would it be. His fees alone (this includes his staff of nurses) would have been well over $30K and that after all the hospital fees and things like the anesthesiologist were paid you might be close to $350K just for the surgery. Since insurance companies have many patients in a given area, they can negotiate fees much lower then their actual costs. While I can agree with this as a good business practice I am astounded at how people without insurance get raked over the coals.

Do I think socialized medicine is the ticket? No, not at all because with that program comes increased taxes, and I do not mean an extra few percent but easily in to the double digits. Quality of care would drop as doctors leave the field due to lower salaries they would make, patients would have to wait much longer for care and on and on. There is a solution though that states should have the ability to negotiate with an insurance company and extend those to the people of the state. This would mean an increase of premiums paid to the company which in turns means more revenues. I do understand that it would also increase expenditures but I doubt that it would bankrupt the company in any fashion. Anyway, I have rambled long enough. These are just my thoughts and reasons why I love and hate insurance.