OT: Making Claims on Health -&- Homeowners Insurance

OT: Making Claims on Health Insurance

Background:

This Sept I was working on my truck in the driveway, all 4 wheels on the ground, no jacks or jackstands. The driveway is about a 12* slope away from the house to the street. The sequence of events are a bit complicated, and not really important to my question. But suffice it to say I made two safety mistakes, and the AT selector was accidentally moved into reverse and the truck rolled downhill about 2 ft pinning my head and shoulder to the driveway, I became the chock that stopped the truck from rolling.

I got out from under the truck, and took an ambulance ride. At first things appeared much worse, the whites of my eyes were filling w/ blood. loss of skin, cuts, broken bones, possible fractured skull. After all is said and done, lots of cuts, some slight muscle damage, a broken & dislocated L collarbone, that's all. I dodged a bullet, will fully recover. Within 2 weeks I was given the go ahead to go back to the gym to start limited exercise, told only if it hurts, back off. Anyway, I got lucky and will have no lingering effects.

I have health insurance through work, that other than the co-payments and one or two small deductibles has coverd everything...except the on call orthopedic surgeon at the ER. He doesn't accept insurance, his ER fees came to approx $1500. So my Insurance company (Anthem Blue Cross Blue Shield) will only pay their "allowable charge" of $450 to me so I can pay the DR, since he is "out of network". So I will have to pay $1050 out of pocket.

I have written a dispute letter to the insurance company arguing that since this was an emergency situation and it was not possible for me to get "pre-authorization". That they should cover the cost in full as is typical of emergency situations. Hoping at least to get at least a bit more reimbursement. I think its absurd to expect the ER Dr to treat a broken & dislocated collarbone in an ER setting for $450. I have not heard back from my dispute letter at this time.

Question:

Would like to hear back from others who have have been in similar situations. I plan to let the dispute run its course. But Looking for whatever advice can be offered to get the remaining balance paid by the insurer.

Thanks, mark

I can't say about your specific case, but it's been my experience (and many others) that insurers' default position is to initially deny anything that isn't totally unambiguously covered. Getting them to cover can take anything from one simple phone call or letter to a multi-year protracted series of hassles (dozens of letters and phone calls, collection agencies, etc.) I have had both experiences within the last few years, in circumstances that were similar to yours in that the coverage seemed logically appropriate, but perhaps not exactly prescribed by policy -- in other words, someone needed to actually think for two minutes and apply common sense and discretion to make a decision. So I would definitely pursue the issue along the lines you are now.

(fwiw, in my experience with two different, long, protracted hassles with the insurance companies, it was often tempting to ascribe malice and evil to the insurers, but I think it really just boiled down to a dysfunctional system. Almost everyone I ever talked to was ultimately just trying to do their job, but few of them are are empowered to actually make discretionary decisions, resulting in many hand-offs, long delays, the need to explain the long complicated problem over and over again, etc.)

Claims on insurance

Sorry, Mark, You cannot collect on your homeowmer's ins. Only OTHER people injured on your property can collect depending on the circumstances involving your negligence, but you can't collect from yourself. If we had National health ins, you would have probably paid nothing

stannp368 said:

Sorry, Mark, You cannot collect on your homeowmer's ins. Only OTHER people injured on your property can collect depending on the circumstances involving your negligence, but you can't collect from yourself. If we had National health ins, you would have probably paid nothing

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Had the perverbial light bulb go on over my head about homeowners insurance claim. Have never made a homeowners claim, and was not sure it was possible, hence my post. When you say it like you did, it makes perfect sense. Thanks for your enlightenment.

I'll just try and continue to dog the health insurance goons and their system.

And with respect to HO insurance: good question. I've heard many claims about HO rates going up immediately after making claims. There seems to be some widespread belief that with HO and auto, even small claims can lead directly to rate increases, and one should consider whether it's cheaper to pay out of pocket for the small stuff, and reserve the policy for larger stuff. Of course, "small" is relative to a lot of things.

That said, I've made one HO claim on a policy I'd had for 10 years, for $5,000 of personal property damaged by a plumbing failure, and the insurance company just paid without any hassle whatsoever and my rates did not change afterward.

I've never been to an ER...so how does a doctor get a job working in an ER but doesn't accept insurance??? I don't get it.
Carl

Cheenist said:

I've never been to an ER...so how does a doctor get a job working in an ER but doesn't accept insurance??? I don't get it.
Carl

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Yea, I don't it get either. I have a letter written, to send to the Hospital, that was "In Network" facility, asking why the hell a Dr on call who doesn't accept insurance?? Agree, that's a pretty silly-assed arrangement.

I see you are local to me...it was Suburban Hospital in Bethesda.

Damn. I hate being a wheel chock. I believe by law, a provider has to accept and file insurance. They don't have to be in your network, though. You might check what you or someone signed to authorize the treatment and payment obligation. If you signed it after receiving a serious injury, you might not have been in a state of mind to understand it. State laws vary, but you might not be liable for the fees charged, depending who signed what and when.

Try getting providers to cooperate with secondary insurance claims!

I know of two situations were a Dr. worked on some one in an emergency situation, and would not take any money from the insurance co, and billed the patient in full, in one case it involved a hand surgeon who had saved a co-workers fingers, the co-worker wrote the surgeon a letter and told him he was only getting money from the insurance co. he couldn't afford to pay the Dr. bill, in that case the Dr. took the insurance money. The other case involved an anesthesiologist used during emergency heart surgery in that case the patient had to get a lone on his retirement to pay the Dr. Universal health care won't stop Dr's from opting out of insurance.

Mike

I have heatd that some doctors are refusing to take insurance. They let you file the claims and do all the work to get reimpursed. Why should they have to employ staff just to deal with the insurance companies?
Bill D.

Don't want this to turn into a debate on health insurance. Looking for advice from those who have been through a similar situation as I have described above. Thanks.

Doctor's Pay

Greetings,

Physicians (and some other healthcare specialists) in hospitals come in two basic types:
1) House Staff - they are employees in the normal sense and the facility usually bills for the care they render.

2) Contract Staff - they provide various services (radiology, pathology, eye surgery, etc.) and they are NOT employees. Their contract with the facility usually says they bill the patient directly. And many, many will NOT accept Medicare/Insurance payments becasue those payments are too damn low.

The above excludes "students," i.e., Interns, Residents, etc.,

When a OB/GYN is paying $180,000 a year in malpractice insurance, someone, in this case, you, has to pay that bill.

Also, and you may or may not know this, some hospitals don't even own their emergency room. Except for the physical equipment, the walls, etc., the whole thing is a totally separate contracted business. Some, even the nearby radiology and minor surgery clinics are separate from the hospital itself.

Regards,
Stan
Graduate Healthcare Administrator (in my evil past.)

Just curious, couldn't you also file a claim under your automobile insurance if you have medical coverage there? After all the vehicle did the damage? Curious also if the ER intake personnel asked if a vehicle was involved in the accident? Uncrichie.

Mike ofthe North said:

Universal health care won't stop Dr's from opting out of insurance.

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Universal health care can most certainly stop Dr's from opting out of insurance . In the Canadian model of Universal Health care It is illeagle for a Dr to bill a patient for medicaly neccisary services. There only option is to bill the single payer medical insurance system

Correct me anyone, but I believe once you are "triaged" & "stabilized", the emergency room provision of your policy has been satisfied. Of course they don't tell you any of this stuff, (like calling in a specialist) may cost you more money. If your luck had been better, the orthopedic guy would have been "in network" and your cost would have been less.

mark thomas said:

And with respect to HO insurance: good question. I've heard many claims about HO rates going up immediately after making claims. There seems to be some widespread belief that with HO and auto, even small claims can lead directly to rate increases, and one should consider whether it's cheaper to pay out of pocket for the small stuff, and reserve the policy for larger stuff. Of course, "small" is relative to a lot of things.

That said, I've made one HO claim on a policy I'd had for 10 years, for $5,000 of personal property damaged by a plumbing failure, and the insurance company just paid without any hassle whatsoever and my rates did not change afterward.

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You can actually save up smaller claims and make a larger claim that involves several small ones. Sometimes Insurance companies worry more about the number of claims than the size.

Here in Kansas, if that was your vehicle and it was insured, that would be a claim on your vehicle insurance. Which would be a good thing if something similiar ever happens to me, as my vehicle insurance is much better than my health insurance.

I know for certain when I bought my car insurance this year, there is a separate total allowance in the insurance rate based on you or them. Often this is seen as 300/150 or 300/300 (substitute higher or lower figures). Of course, whenever talking about insurance, your state, county, locale, or whatever divisional boundary may differ.

As an aside, I'm a somewhat detailed kind of guy. When receiving quotes based on coverage, my agent didn't even know this off-hand. She had to figure it out and call me back! Oh... I love insurance minutia

Glad you're okay, Mark.

Car insurance is the policy to secure your vehicle, it is a support after you stuck with an accident and we all should to get insure to our car.

I had a similar problem once about 2 years ago. Found out from the Insurance co. That once in the emergency room , when the Dr. comes in you had better ask him does he accept your brand of Insurance . If not you tell him to leave and to get some one who does to see you. And they will do that. You look at the price before you buy something . You had better ask the Dr. what is charge is before he works on you. Some times you can`t afford him.