Gov Career

By Phil Piemonte

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Entering the gray zone

Much health care debate has focused on the cost, availability and quality of health care. At the same time, we hear somewhat less discussion of the quality of the insurers themselves.

I'm not referring so much to the question of which procedures are and are not covered, or how much an insurer will pay for a given service, but rather how insurance companies conduct themselves, and how they interact with their subscribers.

This is an important consideration. Health insurers generally lay out the terms of their coverage in very clear, black and white terms. At the same time, insured parties sometimes find that there are a lot more gray areas than one might expect. And when it comes to gray areas, insurers enjoy the advantage.

If you have ever entered that gray zone, you know it can be a scary place. A personal example …

It concerns one of my sons. His birth, actually.

When my younger son was about 18 months old, I received an invoice in the mail that listed thousands of dollars of unpaid medical charges related to his birth.

Bad news.

First reaction: How could this be? We had insurance!

I immediately got on the phone to this particular health care provider’s billing office and found that the insurer had never paid the bill. Naturally, this concerned me. But it worried me all the more because our family had switched insurance companies about two months after my son’s birth.

Very bad news.

I found that, for one reason or another, the insurer had rejected the provider’s first (and only) claim. The provider did not resubmit, I was told, because the provider only submitted a claim once. After that, apparently, the onus was on me to clear up the problem and resubmit the claim.

I had been informed of this (evidently) by one (and probably more) of the dozens of medical statements that had showed up in the mailbox in the weeks and months after my child’s delivery. I, of course, when I had seen the full amount on that invoice, must have assumed it was still in the adjustment process, and thrown it in the stack with the others. I must have done this (I was told) more than once.

Extremely bad news.

There was only one thing to do: I dug out the expired insurance card and got on the phone to the former insurer.

The results of the first call were not good. And neither were the results of subsequent calls as I worked my way up the insurer’s chain of command over the course of several days.

There was a window of time for filing these things, apparently, and I now was outside that window. The fact that the insurance company had not been our carrier for quite a while did not help matters.

Finally, someone at the insurance company kicked it upstairs again, this time to the very top of the stairs. To someone who had a meeting once a month just to look at things like this.

In a couple of weeks, the call came. The company’s decider-in-chief had elected to pay the bill.

Which I (of course) thought was the right thing to do. I thought that, in the end, the insurance company had acted in a responsible and reasonable fashion. We had, after all, been covered at the time of service.

I, of course, thanked the caller profusely. And did a little dance after I got off the phone.

This was a long time ago. That baby is now a college senior.

I don’t know what laws or regulations may have changed since then. And I don’t know if the insurer really didn’t have to pay up, or whether they really did and were just hoping I would go away so they could save a few bucks.

But I just have a feeling that someone entering a gray area such as this today might have a tougher time of it than I did those many years ago.

Who agrees or disagrees? Got a story? Share it here.


Posted by Phil Piemonte on Sep 07, 2012 at 4:02 PM

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