Task a Day Insurance: Preventive Insurance Shopping: Ask to see the provisions of your insurance contract. If you've got the time or the inclination, write a letter to the insurer or a newspaper about what you discover--give them notice.
One of the biggest putdowns some people can imagine is to call someone a conspiracy theorist. In fact, because conspiracy is the secret relationship between two or more people to commit an illegal act, lots of times allegations of conspiracy are difficult to prove. Divining intent is a difficult task. There is an old expression that says the proof is in the pudding---if the act resulted in something illegal, then the intent can be inferred from the act. However, it's not that simple. One of the key ways to strengthen an argument about conspiracy or other intent dependent crimes, however, is NOTICE. Most of us know this on some level--if we see a cracked sidewalk or other peril that could injure, we notify the person responsible so that in the event something happens that person can't claim he didn't know eg that he didn't have the intent.
With health insurance, however, we don't hold health care providers or health insurers to this standard. Even when we are held to that standard. You will not be eligible for insurance coverage if you don't inform your insurer about your current health. You cannot hold your doctor responsible if you don't provide full information. Insurance fraud departments are dedicated to recouping payments from individuals if the insurance company can find a way.
The health care and insurance industry are fraud experts of a sort. When looking after their own money they have staff that investigates, hotlines for reporting and entire departments addressing fraud. As consumers, we too should be addressing fraud. Fraud is the deliberate misrepresentation of a material fact relied upon to the detriment of the person who relied on the misrepresentation. That would be any person who thought he had insurance coverage that did not pan out. That's why insurance policies are so long--their text painstakingly carves out all the contingencies, all the reasons that they won't pay. And the insurance agents? Well, you know the routine, every contract contains the clause that only the text in the document is the agreement, nothing else, in other words, what your agent tells you is not your agreement with the insurer.
Given the fact that we all hate reading through insurance policies, what can we do? Most of us assume we're covered and in the event we have an issue we step up to battle the insurance company. There are however, a few things that we should be doing preventively.
Ask questions about coverage and ask for reference points in the contract that explain your question. For instance, if you have a vision plan that pays for an annual eye exam and a pair of glasses up to a certain dollar amount, and you return to the eye doctor for an eye infection are you covered by that plan? The answer is no. You'd have to submit the claim through your medical insurance and that cost would then be handled by that leg of your insurance coverage.
If your participating provider leaves the plan during the year, how can you get a waiver to see the same doctor for the remainder of your benefits year? Your provider does not run his contract with your insurer during the same period of time as your benefits year. He could leave a day, a month or a week after you sign onto your insurance for the express purpose of using your doctor. Is there a waiver available? Appeal? If so, where in the contract does it address this and what are the time requirements for the same (eg will you get a response within a day, a week, longer?).
How many miles are considered reasonable to travel to obtain the services of a provider? Five? Fifty? And if a plan does not have a provider for the services you need, what is the procedure for obtaining a waiver where the plan will cover your medical needs?
Health insurance plan coverage of check-ups, testing, wellness programs is all pretty much addressed because it's cheap. It is treatment that is expensive. There are plans that include dental that consider you covered if their provider pulls a bad tooth rather than trying to cap it. You want a cap, you spend your out of pocket dollars--retail. There are plans that consider transplants experimental based on survival rates and you have to hope that their physician reviewers will have any level of compassion that exceeds the bottom line (recent Cigna case).
Conspiracy theories: Well, maybe not. Fraud? I think so. We are being sold more and more insurance for less and less coverage. We are relying on the notion that we "have" health insurance that has more extensive lists of uncovered services and medications than ever before. We are being told that just one more insurance policy should fill that gap. And for our final days, long term care insurance is the new must have for spring. It's not that we're stupid, it's that we are not focused on our own priority--Health care--. By confusing health insurance for health care we have weakened ourselves to bargain basement shoppers for any insurance plan, and then have tried to accessorize those bargain basement plans with other insurance plans to dress them up. It's not working. And now that we've determined that we will continue to buy insurance based only on price, the providers and insurers are raising the price of those bargain basement plans. This year you'll pay more for your dollar store insurance and it will cover less.
