Monday, October 7, 2013

It's October so Time for Our Health Insurance Company to Play the Dumbass Card

It's October, we have fulfilled our out-of-pocket deductible for out-of-network providers. So that means that the insurance company has to start refunding some of our money. But lo and behold, now suddenly they keep claiming they are not receiving the out-of-network bills. For some reason the way we sent our bills all year seemed to work just fine, and they knew what to do with the therapy bills sent. But now, apparently I don't know how to accomplish the most simplest of tasks like faxing papers. Of course, all the other papers we faxed at the same time as the therapy bills went through without a glitch. Does make a person wonder, doesn't it?

As a note, they also tried to pull this last year at this time. In fact earlier in the year, the insurance tried to get away with not paying for orthotics for the hubby even though it specifically says in our policy that they will pay for orthotics. The irony is that our company is self-funded through a private insurance, so in truth it ends up costing the insurance company nada. I wonder however, if at the end of the fiscal year, if there is money left over from our company's account, who gets to keep the overage? Does the insurance company get to claim the overage as an asset? Can't figure out why the insurance would care if our corporation had to pay out on the policy unless it effected the insurance's bottomline in some financial way.

Meanwhile, I have a call into hubby's benefits people to get them to help. Last year, they were finally able to get us our money back. But its just that this is ridiculously annoying. We pay for our own insurance and believe you me its anything but cheap.  I merely want what I contracted to receive. I took care of my part and now its time for the insurance to live up to their part of the deal.

But at least I do have some recourse and people to help me access our rights under the policy. Then in New York State, we also have a state run agency that will help if the insurance company doesn't live up to their obligations. But I wonder what will happen to those who only have government to rely upon for their healthcare. (Yes I know we have that already in some way through medicaid and medicare. But at least with medicare, they can purchase medicaid insurance plans like that offered through Humana. So you are not just dealing with government largesse or malaise.)

As it stands right now, if we don't get what we are entitled to, the state can go to bat for us and even sue the insurance group if there is an egregious violation. But you can't sue the government if it doesn't let you. It's called sovereign immunity. So even if the government screws you, you are basically shit out of luck. Nice system, right?

In the meantime, Hubby and I were talking about how once Mr.GS turns 26 he may have to rely on government healthcare if he can't get a health insurance  policy through a job or if an individual private-policy-insurance will be so costly as to be unaffordable. Part of me is happy that he will have some kind of  healthcare but another part of me is very worried about what they will give him, how they will respect him and who will fight for him against the government if need be.

Governments have a finite amount of money to spend on anything including healthcare. There will have to be choices made and these choices will be made by bureaucrats. Will they decide that a youngman with autism, no matter how high functioning, will have no right to certain health needs because of his disability? This is already  de rigueur for some medical procedures, like transplants. Honestly, this is a system I am not looking forward to having Mr. GS  join, but not sure what the alternative would be though, or even if one exists.



Elise