A new book by Stephanie Cohen, CEO
Golden & Cohen, www.golden-cohen.com
Welcome to the first entry of the book we’ll be publishing in 2010 entitled, "You gotta laugh: Life in the trenches of the health insurance business." The goal is to find a way to improve the U.S. healthcare system for everyone. We truly believe that by talking about this issue, and starting a conversation about what changes need to be made and how we can make them, we will be able to move mountains.
What do you do when you have it in writing from your insurance company that you have maternity coverage — but when you go to use the benefit, the customer service department tells you otherwise?
The situation:When our client Randy, a nurse, found out a few years ago that she was having her first baby she was thrilled. Immediately, she called the insurance company to confirm her pregnancy benefits — the fundamental first step prior to having any major test, ongoing therapies or any surgery.
To Randy, making the call was merely a formality, because when she originally purchased the policy years before she was single and didn’t opt for the maternity rider. However, after she got married, she added maternity coverage because she knew she’d someday want to start a family.
Indeed, when she made the call to the insurance company, they confirmed that she had the insurance she needed. However, after her first check-up at the OB/GYN, she received a letter saying she was, in fact, not covered.
Panic ensued, followed by a slightly hysterical call to our office. We quickly phoned the carrier, and unfortunately it took two weeks of repeated calls to them to get the information we needed. At last, we received an email from a reliable supervisor confirming that the rider had been added and she was covered.
Fast forward to three years later. Randy once again is pregnant, and following proper health insurance protocol, she called the insurance company to notify them of her condition. Here's the shocker: The agent on the line tells her she has no coverage. Surely this was a mistake, Randy thinks, so she hung up, composed herself, and called back.
This time another agent told her that she herself had dropped her maternity coverage the day her first child was born. Who would drop coverage on the day they are in delivery, she asked? Most people in the throes of 27 hours of labor are not calling their insurance company.
Frustrated and confused, Randy called us and we remembered she received an email from the insurance company months earlier stating that she had maternity coverage. We both had saved the letter, and we promptly took it to the head of the claims department.
Still, despite the fact that the letter clearly stated that she had maternity coverage, it took three people making nine calls for four weeks to get a definitive answer that Randy did, in fact, have coverage and that the policy would pay for her delivery. What we never did discover was why the coverage was dropped in the first place. Who authorized the change? And why did it take so long to resolve the matter?
You gotta laugh.
Here’s how you can take control
1. When you are thinking about getting pregnant, call your broker or insurance carrier to confirm that you are covered.
2. Make sure to get the name and telephone number of the person you spoke with, the department and supervisor’s name and telephone number, and the reference number for the call.
3. Always write down the date and time that you placed the call.
4. When buying a policy, if you are of childbearing age, be certain that you are covered for maternity.
5. Get a copy of your contract and review it carefully to be sure you are covered for all the potential situations that you may need the insurance for in the future.
If I were the health insurance ambassador
If I were in charge of health insurance policy, I would require every carrier to clearly outline and explain what is covered in the policy. When amendments are made, the policy needs to be updated and the customer needs to be notified. I would also post these changes on the insurance company’s website using easy-to-understand language.
Too often, this information is buried in the policy and is difficult — if not impossible — for consumers to understand. I’d also make sure that carriers were required to respond to issues like Randy’s within 48 hours, so as not to leave paying customers hanging. This is their health we’re talking about, and they are spending large sums of money and trusting that the insurance firms will fulfill their end of the bargain.
I often ask myself, why is this such a big problem. Is it corporate greed? Or are health insurance companies so big and bloated that no one knows what is going on? Either way, there obviously needs to be a change in the system.
The painful truth
The reality is that for now consumers are stuck having to fight for their rights and too often their calls are not returned in a timely manner. This serves to frustrate them more, and makes the insurance industry seem like an even greater villain. For now, there’s little that can be done to change the system. The best solution for the consumer is to know what you are buying, ask a lot of questions, and have a great broker that you can trust.
We encourage you to share your insurance nightmares with us, too. Send an email to our newsletter editor, hope@inkandescentpr.com.
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