I think I have gone crazy.

[saraandmichael]

I cannot stop obsessing over wanting to sue my health insurance company. And I don't even like lawsuits for silly shit, but I am so effing tired of their big profit mission that it would feel good to slam them in open court and all over the media.

[Deleted]

Why do you want to sue?

[saraandmichael]

Mar 9, 2014 10:37:17 GMT -5 elle said:

Why do you want to sue?

I don't know if its a reason to sue or not, but they keep dicking me on coverage for Evan.

I was finally pushed over the edge on Friday when I found that lab work for E will need to be an OOP expense due to the plan we have (its a PPO).

Quick background is that we switched to this company beginning 01.2013. When I was going through the offered plans (we have insurance through my husband's work) I called the new company to get several specific questions answered on three separate occasions to look for consistency in the answers. And each time I called, the representatives told me that they could not answer my questions, as the plans were not currently in effect so they could not look up the policies and see their benefits. It made sense to me at the time, so I then took to choosing a plan based on the PBM for his specialty pharmacy in order to choose someone to provide his medication.

The second week of 2013, as I was in the midst of having his factor order sent out from the new pharma that we chose, I was met with an abrupt call from a nurse case manager that told me all meds had to come from X company or that I would have to pay OOP for them, and since the medication is not billed under major medical that I would be responsible for all costs associated with the medication (which runs $30k/month) but could try to push for coverage after I paid.

I had serious issues with the nurse case manager, who did not do her due diligence when asking for assistance in making other care arrangements for E, and severed all ties with her in March of last year. I also called her superior to discuss her actions, was denied the superior's name and contact information by customer service, but was told to leave my name and return information to have her get in contact with me. She called and left me a message a few days later. I returned her call, three times, with no return phone call ever.

At the end of 2013, I again contacted his insurance company to compare plans relating to specific coverage questions that had not been answered the year prior regarding the different plans. I was again met with "I can't tell you those things, as you don't currently have that plan" by customer service reps on the phone. I spent an entire day at a branch office to speak with representatives about the different plan options. Once they understood that these were options given through a company they realized that their ability to help was limited, but they went above and beyond the scope of their jobs and sat making phone calls to their corporate HQ contacts on my behalf to look for answers to the questions I was in search of. They, too, were met with the same jargon I had heard over and over again.

I then met with the benefits admin from the third party company that is in charge of health insurance to try and get answers, but he isn't a rep of the insurance company itself, and was privy to less information than the reps of the actual company that I spoke with. Since we were given only 5 days to choose our plan, we continued with the one that we had the year prior and took the steps that we were told to take to look for coverage for specific tests for E.

At the end of December, I found out through the insurance company that a request for pre-authorization for labs for E was never filed in their system (something that his hematologist had submitted through the nurse case manager that I had severed ties with), even though she had told his hemo nurse that the request had been denied.

The hemo nurse again submitted a letter detailing the medical necessity of the labs to be drawn and processed at a specific lab on January 7th of this year, and when I called to check on the processing of the request Thursday before last, it was again found that there was no record of the request, even though this time his nurse had a fax receipt showing that it had been received.

I explained the entire situation to someone in the pre-auth department (after nearly two hours on hold waiting for someone to take my call). She was an excellent amount of help and worked really hard to move things swiftly and through the appropriate channels so that we could go ahead and get this covered, since he is in need of labs. After speaking with several people in her department, it reacehd a dead end in that we are responsible for the costs of the lab until we meet our deductible for OON expenses ($5k) and then at the co-insurance rate until we meet our OOP max ($10k) for OON benefits.

It seems, however, that if we did not have OON benefits that we would be able to get the pre-auth to have these labs covered (and either be responsible for our regular deductible and max OOP expenses that we cap out on every fucking year anyway). Which means that if the insurance company would have looked at the benefits offered by the other plans we had available to us and had answered the questions that I had asked of them in November 2012 and November 2013, that I would have chosen an HMO plan that afforded us the ability to have the labs potentially covered.

[saraandmichael]

ok, I know thats super long. I didn't mean for it to be, but i'm wordy.

and i am sure that i can't sue because of it but I am so effing tired of having to fight at every corner for basic coverage to keep my child alive. I am already locked into having to receive life-sustaining medication through a subpar company on a monthly basis, even though they have fucked up every order since October 2013, and I have no means to change this.

we shell out thousands of dollars every year for deductibles and OOP maxes and I would just like someone to give a shit about our family and the financial stability that we seek instead of pissing all over someone that is trying to choose between keeping their child alive and in good health and keeping their family afloat.

[Deleted]

Wow. That's a tough one. I would absolutely be frustrated. That might be a claim. I could see a negligent omission claim if there is any sort of duty in that relationship, and an insurance lawyer might have more ideas. I think I would talk to a lawyer in that situation, and if they can't help go to the media. Have you spoken to any activist groups to see if they can help?

[pantsparty]

I can't fucking believe they won't tell you what things may or may not be covered in a plan you are considering. That really blows my mind. I am FURIOUS for you.

[saraandmichael]

Mar 9, 2014 11:21:07 GMT -5 elle said:

Wow. That's a tough one. I would absolutely be frustrated. That might be a claim. I could see a negligent omission claim if there is any sort of duty in that relationship, and an insurance lawyer might have more ideas. I think I would talk to a lawyer in that situation, and if they can't help go to the media. Have you spoken to any activist groups to see if they can help?

I haven't, as most of this is new information (well, the part that has pushed me over into wanting to nail asses to the wall). I wouldn't even know where to begin. I'm just so frustrated by it and really emotional over it that I haven't been able to think with a level head about it yet. I do know that we aren't offered a plan with a deductible that isn't effing crazy high (and we have chosen the plan offered with the lowest that we could afford) and are capping out our expenses every year.

I am honestly to the point where wasting medical resources makes more financial sense to treat his disorder. And I hate that I think that way. It's just such a clusterfuck of a system that doesn't account for his actual needs and it makes me sick.

[cleo29]

I don't have any advice, I'm just sorry you are getting jerked around by this company.

[kristie]

Does E qualify for ssi disability and/or Medicaid? I think income requirements don't matter when child has A documented disability. I know this can differ by state though. I know this has nothing to do with your current frustrations, but I would think Medicaid would be easier to navigate for a child with a documented disability vs fighting every step of the way with insurance companies. I can't even begin to imagine the frustrations. I hate insurance companies so much.

[MWOS]

Somewhere at sometime some lawyer sat down and said, the risk of doing X outweighs the risk of getting sued. It's perfectly reasonable to see if that lawyer was correct.

Take my opinion with a grain of salt. In another lifetime, I must have been some kind of fly by night ambulance chaser lawyer because I love suing. It's not personal, it's just business.

[saraandmichael]

Mar 9, 2014 12:34:08 GMT -5 kristie said:

Does E qualify for ssi disability and/or Medicaid? I think income requirements don't matter when child has A documented disability. I know this can differ by state though. I know this has nothing to do with your current frustrations, but I would think Medicaid would be easier to navigate for a child with a documented disability vs fighting every step of the way with insurance companies. I can't even begin to imagine the frustrations. I hate insurance companies so much.

no, we don't qualify. but honestly, that isn't a road i'd want to travel down unless absolutely necessary. dealing with medicaid would be a far worse venture than i have been part of in this.

[saraandmichael]

Mar 9, 2014 12:37:08 GMT -5 MWOS said:

Somewhere at sometime some lawyer sat down and said, the risk of doing X outweighs the risk of getting sued. It's perfectly reasonable to see if that lawyer was correct.

Take my opinion with a grain of salt. In another lifetime, I must have been some kind of fly by night ambulance chaser lawyer because I love suing. It's not personal, it's just business.

you know, thats part of what is so fucking infuriating when i go through this shit. that some actuary or some lawyer looked at some numbers and some laws and predetermined how to treat a disorder they know absolutely nothing about. and its so not one size fits all even within the confines of dealing with hemophilia that as experienced as i am with dealing with it, i couldn't properly throw rules around it.

ugh. and now i'm crying. i'm sitting here looking at my perfect little kid who knows nothing about this and doesn't deserve to have to deal with this bullshit for the rest of his life. i hate hearing people say 'it's not fair', but this whole disorder and what it can and has done to him and will continue to do physically, mentally and emotionally just isn't fucking fair.

[muffin0]

I know nothing about insurance and law and medical stuff. but I do know that E is SO FUCKING lucky to have you as a mom!

If you need anything let me know, whether it's to hold a picket sign, hold the punching bag, or get drinks.

I was thinking about you the other day when I got a Hemo walk thing in the mail.

[cville]

This is bullshit. I agree with elle. Something has to be done.

[lilibet]

You should be able to file a complaint with your state insurance department for all the stuff you've had to deal with.

If there's only a certain lab that can do the test you should be able to get a waiver that would allow that lab's claims to process at the in-network benefit level. I'd keep calling and maybe ask to speak to a manager. Do you have a site for your insurance that you can submit questions through? Those reps tend to be able to do more in depth research on issues because they aren't under quite the time crunch.

And I can tell you for the company I work for that it's true that customer service reps can't see benefit info for other plans. The only thing they can see is the info for the plan you're currently enrolled in. Also they don't get info on plans employers are offering. That stuff isn't available to reps until you've selected your plan and it's gone into effect. Even then it can be a few weeks before it's loaded into the system they can access. It's the dumbest thing ever and super not-helpful but it is the truth.

I work in insurance and if you've got any questions I'm happy to help. I hate hearing all the stuff you're having to deal with

[cst2cst]

How big is your H's company? Do they have a benefits person? When my insurance fucked with me after dd was born 13 weeks early (instead of adding her to our family plan they reset my high deductible and then "fixed" it by paying old claims that I had already paid in order to meet my deductible. Then they said it was my job to go after those providers who were double paid to get my money back and keep paying on the reset deductible. In all my free time with a baby in the NICU) I eventually got management and benefits involved. They were able to access back channels in the insurance company that I couldn't reach and get it fixed. I worked for months on that nightmare and they fixed it in weeks.

[leeann]

Is there an HR person internal to the company? That's who normally provides the info on the upcoming year's plan options.

[firedancer49]

Like the pp asked, how big is the company your dh works for? They should be able to help you and should have been able to provide you with summary plan descriptions for your plan options. It's something to know for next year. Their benefits staff may be able to help you with their insurance company account managers and get things moved on. They can stay on their ass.
Can I also ask which PBM you are working with? Feel free to pm me if you want, but I may be able to get you contact names and numbers.

[saraandmichael]

cst2cst, leeann, firedancer49

my husband's company has around 50 employees. when they switched insurance companies they began using a third party company so their HR person (who I called to speak with about the available options in late 2012) is unable to help and referred me to the third party company that manages their health insurance benefits.

lilibet, I understand what you're saying about a CSR having limited knowledge about plan benefits, though I would think that with a plan number they should at least be able to look it up? I did, however, ask them who I could speak with that would be able to answer my questions and after the 'let me talk to my manager' bit, they came back and told me that nobody in the company could help since the plans weren't being offered at the time (this was before we made the initial switch). However, when I asked the same things this year, I was cockblocked from every available angle.

Also, the person that finally answered my question this past Friday is in the pre-auth department and gave me as many options for coverage that my plan would allow for that would minimize my OOP costs. However, there was only one alternative and that does not address the issue itself and isn't a viable option.

[leeann]

Is it an employer sponsored plan?

[firedancer49]

Mar 9, 2014 18:56:25 GMT -5 saraandmichael said:

cst2cst, leeann, firedancer49

my husband's company has around 50 employees. when they switched insurance companies they began using a third party company so their HR person (who I called to speak with about the available options in late 2012) is unable to help and referred me to the third party company that manages their health insurance benefits.

OK, this is bullshit and I am upset for you. They set their plans up as options to pick from, they have those answers. How can someone make an informed decision on their health without this information.  Maybe a phone rep couldn't help but the account manager should have stepped up.  You should have been able to talk to a a manager who would have gotten you this information. 

Id definitely make a complaint to the employer about this. Granted it won't fix much now but it's worth it.  

[saraandmichael]

Mar 9, 2014 19:06:01 GMT -5 leeann said:

Is it an employer sponsored plan?

yes.

[leeann]

It's not acceptable for his employer to wash their hands of this by handing you off to the outside carrier. If they do have 50 full time equivalent employees, they do have to follow the regulations and provide SBC and other information to employees.

[frannyr]

Mar 9, 2014 16:29:51 GMT -5 lilibet said:

You should be able to file a complaint with your state insurance department for all the stuff you've had to deal with.

I know it's a PITA but you should take this advice and file a formal complaint with your state's Department of Insurance.  The insurance company is required to respond timely to your complaint and the DOI will be the middle man and make sure they do so. Have you filed a formal complaint (not an appeal) with the insurance company?  Again, no one should have to deal with this but it may be a route to get your situation looked after.

Although you are not allowed to change plans mid-year unless you have a life-changing event, you feel mislead and did not have enough information to make an informed decision when choosing plans. Your husband's HR may agree and allow you to switch. 

[kjh]

You can take any complaints to the state corporation commission and see if they can use the info.

[DotAndBuzz]

Ugh, this is just such complete and utter bullshit. I hate that you are dealing with this.

[saraandmichael]

Mar 9, 2014 19:24:14 GMT -5 frannyr said:

Mar 9, 2014 16:29:51 GMT -5 lilibet said:

You should be able to file a complaint with your state insurance department for all the stuff you've had to deal with.

I know it's a PITA but you should take this advice and file a formal complaint with your state's Department of Insurance.  The insurance company is required to respond timely to your complaint and the DOI will be the middle man and make sure they do so. Have you filed a formal complaint (not an appeal) with the insurance company?  Again, no one should have to deal with this but it may be a route to get your situation looked after.

Although you are not allowed to change plans mid-year unless you have a life-changing event, you feel mislead and did not have enough information to make an informed decision when choosing plans. Your husband's HR may agree and allow you to switch. 

I have not yet filed a formal complaint with the insurance company. I am in the middle of writing a letter regarding the incident with the nurse case manager that I dealt with, but I was told the address is a generic po box that I send it to, so I haven't got high hopes for a resolution.  I wouldn't even begin to know where to file a complaint about being mislead about an offered plan.

[saraandmichael]

Mar 9, 2014 19:18:24 GMT -5 leeann said:

It's not acceptable for his employer to wash their hands of this by handing you off to the outside carrier. If they do have 50 full time equivalent employees, they do have to follow the regulations and provide SBC and other information to employees.

what is SBC?

[leeann]

You are entitled to access to coverage information - a summary of coverage and a summary plan description under ERISA. The DOL website lists out the employer obligations.

[saraandmichael]

Mar 9, 2014 19:19:16 GMT -5 @booby said:

Mar 9, 2014 19:12:05 GMT -5 saraandmichael said:

yes.

so frustrating, sara.  dumb question and you've likely pursued this already, but can't M talk to someone on the employer side?  this worked for me when i was trying to get something covered for H.  i had to back door my questions and in the end, i wasn't able to get the resolution i wanted (b/c we are indeed, NOT covered, so not the exact same sitch as you), but i was at least able to get a fucking answer that way.  i was so furious of all of the red tape i had to go through and i am really sympathetic to your situation b/c it seems you have to do this many, many, many times a year.

I haven't had him speak to anyone. I did get the name and number for the HR person at his company so that I could speak with her directly, but she couldn't (wouldn't?) answer any of my questions.

Honestly, it doesn't make any sense for him to have any part in this since his only real tie to it is that he is employed there. He doesn't know much about the deal with the insurance (other than what I tell him) and since its such a vast and convoluted ordeal, I spare him the details.

And I do go through this so many times per year. Its infuriating. Not just the amount of time I spend dealing with this bullshit, but the amount of money that we spend every year on health related costs. We could probably spend two weeks in europe once a year as a family of four if we didn't bleed out so much money toward hemophilia-related costs.