Friday, October 17, 2008

Just a little rant on the subject of insurance

I'm not here to discuss politics and I am not addressing the issue of the millions of Americans who do not have access to medical insurance. I'm speaking directly to those of you who do have employer sponsored insurance coverage. I work in this field, specifically in customer service and claims processing. In the past few months I've noticed an alarming problem: A complete and total lack of education on the part of the insured. No one understands how their plan works, how much it pays, what you as the insured are going to have to pay out of pocket, what is covered and what isn't. I am going to place a small portion of the blame for this on the employers, but the bulk of it I'm placing on your shoulders, the insured members. When you were hired you were given plan documents, a Certificate of Coverage and a Schedule of Benefits. (If you weren't, go to your employer and demand these!)

Now assuming you have this, did you read it or did you throw it in a corner to collect dust? If you didn't at least look it over, you should. These documents contain very important information you need to know. Among the things you should know are:

1) Do you have a deductible? If, yes, how much is it? Is it based on a calender year?
2) Which services does it apply to?
3) Do you have a copay or coinsurance?
4) What is the percentage of your coinsurance?
5) Does your plan have a wellness benefit?
6) Does your plan have a pre-existing clause?
7) Is your plan an HMO or a PPO?
8) Is your plan fully insured (expenses paid by the insurance company) or self-insured (expenses paid by the employer itself)?
9) Are you covered if you travel from home?
10) If you are admitted to a hospital that is contracted with your plan and they call in a specialist who isn't, will his services be covered?

There is so much more you should know and it's all contained in those documents. TAKE THE TIME TO READ THEM. If you don't understand something, by all means, please ask for clarification. All I'm trying to say here is, take the responsibility and educate yourself so that you are not surprised next time you receive a denial from your insurance company. Also, if you have educated yourself, not only will you understand their reason for the denial, you will also be in a better position to refute the denial if the insurance company has made a mistake. You may even be able to avoid getting denials entirely, just by following your plan's guidelines.

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