I am covered right? Maybe not!

I hope you enjoyed Red Jade’s account of her experience with home insurance. It reminded me of my ongoing nightmare with my health insurance. I have often heard that medical bills are one of the top causes that people file bankruptcies in the United States. This hit close to home recently when I used my insurance.

I typically read every plan document for every policy that we purchase. I pay special attention to the benefit limitations and lifetime maximum amounts. I make sure that my provider is in-network before I make an appointment and even check if any referrals made are in-network. I have even been so paranoid as to check whether a lab was in-network. This comes from being a plan administrator and trying to help countless employees navigate their insurance claims.

It is in the same spirit that I selected a provider to resolve some health issues. As usual the doctor referred me to a partner in his practice who was more experienced with the issue. As usual I checked my insurance company website to make sure that the new doctor was in-network for my plan. I went for my visit and had a minor outpatient procedure and yet again I verified that the address was listed as in-network. This was in July of 2010. I had almost forgotten about the whole thing until the other day I opened a bill from a surgery center I did not recognize telling me I owed $5000. When I did further research, I found out that the claim was processed out-of -network and the $11,000 that was paid to the facility was not enough.

I am in the process of appealing this claim with the insurance company and I will let you know how it turns out. I helped one of our employees with a similar claim. His doctor ordered for him to do a stress test I the same office as the doctor. It turned out that the diagnostic part of the clinic was not a part of the plan. We appealed the claim with the argument that there was no way that the employee would have known that because they were in the same location. We won the appeal for the employee and he does not owe anything above what the insurance paid.

To avoid any medical insurance nightmares, be sure to check the following

• Does your plan have any provider restrictions?
• What is your deductible? It can vary depending on the treatment
• Do you have a lifetime limit? (This is a very important question in the event of a chronic illness)
• What are the benefit limitations or what does your insurance not cover? 
• It is always a good idea to browse through your plan document. If you do not have one, ask for one from your insurance provider.

Other things to keep in mind:

If you have a plan that has in-network and out-of-network deductibles (which is pretty typical), the two deductibles never meet. For example if your out-of-pocket maximum was reached in-network, you can still pay more money by going to an out-of-network provider. The out-of-pocket maximum for out-of-network providers is usually much higher than in-network. Being in-network means that the doctor/medical provider is contracted with your insurance company and offers a discount to its members. 

I would love to hear your questions or experiences with health insurance. Meanwhile I will keep you posted on my ongoing claim issue. Ironically I spoke to my friend in Canada who has two little ones. She remarked at how easy it has been to get the care she needed for her children and I could not help but be a little envious:-)