Simple health insurance claim turns into chaos
About a year ago while chaperoning my daughter in a trip to Hershey Park, I had a mock serious discussion with a parent of one of her friends who holds a management position with a Philadelphia hospital.
The question was whether we would prefer to submit a claim to government, such as Medicare, or to a private insurer. His choice was insurance, the reasoning being that, if insurers denied TSGLI claim, they could be sued. I questioned that reasoning, since delay in processing a health insurance claim when someone needs services, can be deadly. The ones that want an insurance plan can learn more about Ieuter Insurance, its benefits and how it works.
I recalled that conversation recently when what should have been a routine transaction in dealing with two health insurers affected me directly. These experiences should have had nothing to do with the Affordable Care Act or changes in the health care law.
At the end of last year but during the open enrollment period I decided to move health insurance coverage for me and my daughter from IBX Personal Choice to Aetna. My insurer had placed additional requirements for sole practitioner attorneys who wanted to renew and raised premiums while lowering drug coverage benefits. I calculated the cost in addition to what I was already paying at about an additional $600 per month.
For the new policy with the new carrier, I completed an application, disclosed all pre-existing conditions, and waited. When it seemed we might not receive a response by Jan. 1, the date I expected the old coverage to end, we asked for an effective date of Dec. 1.
A notice went out from the new carrier dated Dec. 6 welcoming me to coverage effective Dec. 1 but doubling the premium. The reason, I understood, was a pre-existing condition. I have had high cholesterol which is completely correctable with medication, heartburn from time to time, and have had one episode of tendinitis after using a leaf blower for yard work. This, I think, puts me in the same position as most adults over 50.
Because of the new development, I changed the coverage to a “value” plan with no coverage at all for brand-name drugs but “lowered” the premium about even with the original premium quoted.
Although disappointed since the brand-name drugs worked for me and now I would need to use a substitute generic, all these experiences could be viewed as mere stumbling blocks on the way to new health insurance coverage. Then came my first doctor’s appointment under the new plan.
The Feb. 3 routine office visit should have been unremarkable except that the claim continued to be rejected. After several phone calls, it was determined that Aetna claimed pre-existing condition — of what condition I did not know — and wanted proof of prior coverage beyond the membership cards previously provided.
Independence Blue Cross said I needed a Certificate of Creditable Coverage. I was familiar with that from Medicare B and D coverages for clients. On March 2 they said they would send one.
On March 29, almost four weeks later, I learned the certificate had not been sent because IBX claimed I was still insured with them. In April, the answer was that it was issued April 9.
The Certificate of Group Health Plan Coverage postmarked April 19 and received April 21 is one of the most bizarre pieces of correspondence I have ever received. It indicates a “date coverage started” for my daughter as 3½ months before she was born. For mine, the “date coverage started” is given as more than eight years later than my daughter although she is listed as dependent on my coverage. Even a good computer program should have picked up that she could not be on my dependent coverage if I had not been covered and before she was born.
Since it seemed that this was the best that could be done, however, it was submitted. Aetna then reissued a premium notice for the original double premium amount and again denied the claim for the doctor visit.
The most recent information online from Aetna states the claim was paid on May 16, although the day that I read this information was May 15. Time travel maybe is a possibility. It also indicated that I may be responsible for the full amount of the claim.
This comes as news services throughout the country are reporting health insurers are experiencing record profits now due, in part, to “low level” of medical use. Maybe others are experiencing the same results.
For more, listen to “50+ Planning Ahead” a weekly radio program on WCHE 1520 on every Wednesday from 4:30 pm to 5:00 pm with Janet Colliton, Colliton Law Assocs., PC, and Phil McFadden of Home Instead Senior Care.
About the Author Janet Colliton
Esquire, Colliton Law Associates, P.C. Janet Colliton has practiced law for over 38 years, 37 of them in Chester County, Pennsylvania, a suburb of Philadelphia. Her practice, Colliton Law Associates, PC, is limited to elder law, Medicaid, including advice, applications and appeals, and other benefits planning including Veterans benefits, life care and special needs planning, guardianships, retirement, and estate planning and administration.