Insurance Nightmare at worst possible time!
 

I'm in quite a situation - My employer is changing our health insurance, and ALL 4 choices they are offering all excluded rsd for treatment or exclude chronic pain conditions for treatment!!!

Oddly enough, about 4 months ago they had us do a mandatory survey about our health, confidential of course, asking very specific info about any diagnosis or medication we were on or had received, and other health related info, in order for them to "shop" out some health insurance companies. I'm almost certain that they used this info, and when the prospective insurance carriers saw rsd/crps they told them it would be $$$$$$ for any policy, so they decided to get policies that would exclude any treatments.

I'ts really messed up, I've talked to the Oregon Insurance Commision, and if the policy's were out of Oregon, they'd be illegal because group policy's here can't have those kind of exclusions, but my coprorate office is in CA, and that's where the policies were purchased, and I guess it's legal there. I'm in the process of hiring a lawyer, the first one I called just happened to have a mother who has rsd in her shoulder, so I figured that was a sign. She said because they did the survey first I have a case for discrimination against them as they can't ask you what your medical conditions are and then shop for insurance like that. But in the meantime, my coverage runs out at the end of June. No one is gonna give me an individual policy, at least not one I can afford. My only even semi viable option is a quickie wedding to my fiancee so I can get on his insurance, but he is just recovering from getting out of the hospital from having serveral surgeries himself from compartment syndrome on his leg and almost losing his foot.

I'm not sure I really have a question . . . I guess I'm looking for ideas. I know I won't qualify for any insurance/government options because I have income and a job and am offered group coverage even though it excludes me, but it seems like there has to be something out there, right? I've called everything I can think of . . . . .

WOW!! I would think you would have a good case also, but it is what to do in the mean time right? I don't have any suggestions at all just know that I am on your side. It is so wrong wrong wrong for them to have done that survey & then shop around like that.

Besides you do you know how many other people are being put on the spot like you are??? Are you union by any chance??? If you would care to share who do you work for???

I am sorry this is happening to you.

DebbyV

Just a thought, explore the options on the new insurance for covering a pre-existing condition. I once had this happen to one of my employees and we found out that since she had a pre-existing condition and this insurance was replacing the old coverage, she was still covered for her condition. The new policy had an exclusion for any new cases or diagnoses that came after the employee was enrolled in coverage. Not sure if this would help, but you might look into it. Good Luck!! Lisa

Something doesn't sound right. Group policies don't have pre-existing clauses in California and I've never heard of RSD as an exclusion, to date. Private policies can exclude whatever they want to but I've not heard that of a group policy. I think I'd want to see that in writing, in the policy. Discrimination certainly sounds like an issue too.

You might also want to call the California Insurance Comissioner's office and do a little investigating.

Hi Holly,
First, I am sorry you are going through such a stressful and hard time.. it's great that you have found an attorney that is willing to help you and understands your circumstances!

I would have him contact your employer and suggest that his mandatory survey was an invasion of privacy and he has no legal right (at least, that's what I would assume, but check with your attorney) to demand private information about your health status, meds taken, prevailing conditions...that is ludicrous to ask of employees...was this an anonymous survey?

Maybe your attorney can convince your employer to continue paying for your present insurance policy which runs out in June, so that the coverage can continue until this is all resolved. he might be willing to do that once your employer has a reality check with your attorney!

I know nothing of labor laws, but your employer's strategy sounds manipulative and wrong...and illegal..
Holly, I hope your fiance is feeling better after his surgeries, and I hope the two of you find a workable solution soon!!
Sending hugs,
Hope4thebest :hug:

So, i found out the new insurance doesn't exclude rsd exactly, it just excludes coverage for any chronic pain treatment. So techinically it would cover things like pt, but it wouldn't cover any meds or pain management at all. But I've been told several different things in the last few days, so I'm waiting til I get it in writing . . . . I've been told rsd was specifically excluded (along with fibro. etc), I've been told it's just the pain managment, I've been told it's only chronic pain treatment . . . . I'm sure I've been told some other things too, but I can't remember them now.

I tried to go the preexisiting route, but the said because the new policy excludes the treatments, it didn't matter. I've tried every angle I can think of here :( It's not a union, it's actually an ESOP, and it spans over several states. You'd think since it's employee owned it would be easier or something, but nope :(

In Oregon, group policies can't have these kind of exclusions at all. I talked to the CA Insurance Commision, and they wanted me to send them a copy of the policy, which I'm doing. It does say clear as day in the exclusions "Chronic Pain Treatment", and the HR dept here is working on writing something up for me using some procedure codes I got from my doctors office (just for my normal monthly visits) saying that with the new policy they would not be covered and are specifically excluded. BOLI's office that oversee's benefit packages is also looking into the legality of this one, and I am seriously considering filing a complaint with them. But, I also have to consider the fact that if I want to hire a lawyer and pursue this I will likely lose my job - that's just how my company is. They will find a way or reason to fire me if I pursue this so I will have to tread carefully. I want to make sure my company compensates me for this, but I also want to preserve my job.

As to the survey they had us fill out, I found the email with the link, and it was still up online! So I was able to go back and print it out. And wow!!!! First off, it was not anonymous! It asked your first and last name, birth date, height and weight, as well as any dependants. Then went on to list a bunch of diseases asking if you had them or not, incuding HIV, mental illness, drug addiction, cancer, heart problems, etc. Talk about HIPPA voilation! Then it asks if you were disabled in any way, what meds you were on, how long, why, if you've been told you may need surgery in the future, what you thought your medical costs would be in the next year, and a few other questions. It ended with a paragraph about insurance fraud and about how if you intentionally lied or omitted information it could be used to deny you coverage in the future. All this was done on . . . . . SURVEY MONKEY!!!!! And according to the email, all employees, whether you were on the companies health insurance or not had to take the survey.

On a good note, I think we may have a found a workable solution :) We are considering getting married now, just a quickie in front of a judge thing, and then still have our real wedding later like my mom is planning, that way I can get on his insurance. He is a federal employee, so all his benefit info is online, so I was able to do all the research while he is home recovering and just bring him the info. I found a plan that would still cover everything I need, and be cheaper then what he is paying right now even when he adds me on (thankfully the feds only have individual and family plans, and he has a son, so he was already on fam, adding me on doesn't make a huge jump in price). So I was able to find a cheaper plan that still covers every single one of my meds and doctors, doesn't have a dedcutible, no waiting periods, exclusions, preexisting, decent copay, and will cover all his/his son's needs to, and save him some money. I think he feels good because he gets to be the 'hero' in the situation :) My mom even thinks it's a good idea, which I'm surprised at. But she realizes how important it is that I have health insurance and that if it lapses how hard it's going to be that she can over look the fact that I'll be married a few months before my wedding . . . .

I've talked to a couple other people at my work who were affected negatively by the change in insurance, but not to the extent that I was.

Your need for medication/treatment would be more reflective of an acute exacerbation, not the need for ongoing treatment of a chronic disorder. Might still be covered because of that. All comes down to what "phraseology" your doc uses in his diagnosis.

I'm glad you found a way around this mess hollyk24, congrats! :) And yes, having lived in the DC area my whole life, my brother who works for the fed and his family are well taken care of by their BC/BS ppo. Me, on the other hand, who works in the private sector lost my coverage because the company went chapter 7. All alternatives where too expensive, twice my mortgage amount per month. The new company I work for has no benefits. The system we have in this country is pathetic and looks and feels criminal. Who needs this kind of stress when they fall ill.

Right Jim... This is so wrong..enough already with this employer..he needs a spanking..lets get married..sue due to discrimnation and aggravation of your terribly painful illness...let em fire ya..they were lucky to have you and you are better off without them! I am all for people with pre-existing should be cut slack and to go thru the back door to get your personal information then build it against you is wrong..wrong!! One more person/group punishing us for something that is out of our control...I am so sorry Holly that this is happening to you...and I am sure your stress level is thru the roof...not to mention your fiancee's health issues...I ma sorry for all of that..and I hope he feels better soon...so...

I want to say congratulations on your beautiful marriage...what shall we all wear to the wedding??

Love, Kathy:grouphug:

Dear Holly -

To everything others have said, I would just emphasize that you have the right to see the exact language of the policy. First things first, you should ask to be given that portion of the policy which excludes coverage for any chronic pain treatment, if they are using that as a basis to deny you coverage.

Then we can discuss whether it's lawful.

Mike

The whole system is rigged to trap and expel those who have pre-existing conditions. One can find themselves in a tight spot in a hurry and its rigged that way on purpose, written by attorneys who are employed by insurance companies. COBRA was passed by congress in 1996 to help those bridge the gap, to avoid the lapse in coverage, in which insurance companies invented. But, what many don't realize if you work for an employer with less than 22 employees and or the company goes chapter 7 there is and never was COBRA to begin with. Just wait and see what loop holes there's going to be with the new health insurance laws. My prediction is not only will insurance companies make a bundle of cash they will, or already have, figured out ways to dump human beings with health issues.

Yes, yes . . . . The stress of it all . . . . In the middle of all of this, I've been in the process of trying to get pre auth for an scs . . . . So literally, the day after my fiancee had his first emergency surgery (so I'd been up all night in the hosiptal, he had 2 blood clots in his leg, they had to slice open his calf and leave it open for 2 days to relieve the pressure from the compartment syndrome) I'm at the pychologist for my first appt :)

The next week I'm there to take the pysch eval . . . . I go back this week to get the results. The guy has already told me that I have "severe" anxiety . . . . I can't wait to see how this test went :) Seriously, you'd think the dr would have enough brians to take into account the seriousness the last several weeks and the amount of stress it would cause on any normal person, let alone any person suffering from pain every day of their life! Yeah, I'm stressed, I haven't slept well, it's affecting my pain, which is affecting my stress, it's a vicious circle, I understand all of that very well. I just need to get this physchologist to understand that I have gone through some huge life changes recently (bought a house, moved in with my fiancee and his son), and now with all this stuff going on, he can't really judge my stress levels and anxiety over the last few weeks as my personality and life as a whole, that's just not accurate or fair. The very first thing I said to him when I met him was explaining the situation with my fiancee and that I'd spent the night at the hospital . . . . He takes notes while I'm talking, so I'd think he'd be able to remember what I say . . . . Regardless, I guess I don't have to worry about the scs for at least a couple months until this insurance mess gets all straighted out. Then I can start all over . . . .

Anyways, I digress . . . . . fmichael - I have the policy info. It says:

Under Exclusions:

Chronic Pain Treatment - Except as specified in the certificate

Now, they will not give me the certificate, however, they have told me that the certificate states that the only situation where chronic pain treatment is covered is in under hospice care. They define chronic pain treatment as any treatment for any condition where the main symptom/complaint is pain that lasts for more then 3 months. They also say that certain conditions are listed under this such as fibro, rsd, multiple back issues, endo, and a bunch of others. The company is working on writing something up for me right now to further clarify exactly why/what is excluded, so I'll post that when I receive it.

Jim -

You wouldn't be any chance be referring to the fact that the Senate bill set up a system of "National Exchanges" without taking into account that insurance companies, registered in State X, could then use a series of Supreme Court cases on banking law to avoid almost any local insurance regulations when administering policies sold in State Y? As in, there is a reason all credit card companies are based in Delaware or South Dakota, just as so many of the publically traded companies are incorporated in Delaware: build the fewest regulations as possible, and they shall come. Something so obvious it occurred to me, but apparently not the 60 fully-staffed senators who voted for it. (My wife, also a lawyer, told me I was crazy at the time, but it had more to do with not having heard it from someone on high than anything else.)

Anyhow, the House picked it up right away and put it in the reconcilliation bill, only to have it be one of two provisions knocked out by the Senate Parlimentarian, as lacking any federal fiscal relevance. Now the Democratic leadership has said it will attach it to a "must pass" appropriation bill or the like. We shall see . . .

Mike

Hi,

It looks like you are finding a solution. You must be very relieved. I just have one question? I live in NJ and I quess I'm lucky I do. NJ has quite a few laws regarding health insurance and the carries have to abide by them such as pre-existing conditions, example if your company should switch insurance companies and you have any condition they can not say will cover you for this and not that it's just not allowed. It was put into law about 10 to 15 years ago. I quess what I am trying to say is what is the law is Oregon, I believe that's where you said you live, even though the main office is in CA they have to abide by Oregon Law. I would contact your state insurance board I believe each state has one..


Good Luck

This scenario is just the start I'm afraid
 

After working with the Medicare SHIP Program for 2 1/2 years and watching the radical changes in Medicare along with supplements on all insurance I've learned a few things. When Medicare Part D drug plan was implemented almost 6 years ago Bush was praised for finally doing something - yep he did. Oh, and he had the bill written so it wasn't even funded till 2010 hence we saw the average drug plan start at $15 per month now costing on average $65 when the deductible expenses are also divided in. Also considerably higher co-pays on everything. Didn't anyone look at the small print?

You're now a front runner hitters where the rest of us will soon join your ranks as insurance bails over this medical problem or that. Problem is, health care simply costs more than we can afford to pay so instead of inflating the premiums to cost levels that will have subscribers dropping like flies, it appears this insurance company decided to place a waiver instead. Sorry folks, but we're only scratching the surface of more to come along with even greater price hikes that are going to put us all in the poor farm.

Right now an average person on Medicare with the drug plan plus a supplement is paying an average of around $300 apiece for insurance not including co-pays on medications or the rest of the doctor bill Medicare plus the supplement won't pay after January 1st of this year when the amounts paid was dropped by an average of 10%. That means we'll all now have a third bill to pay even when you do have a Medicare supplement.

I really feel bad for how you guys are being hit, but please move over - the rest of us are also on the same sinking ship, we just don't know it or are choosing to deny it. Now isn't this a great case of when the truth really does hurt.

Im not sure why exactly, but when I spoke with the Oregon insurance commisioner, they told me since it was a California policy, that Oregon's laws wouldn't have jurisdiction over the matter :(

Oregon law wouldn't allow this to happen, it's similar to NJ. But CA seems to have some pretty lax insurance laws or something, every place and person I've talked to at a state or federal level has said they'd look into the policy, but that it seemed to be within CA's laws . . . It seems wrong that a company that is located squarly in Oregon can do this, it's complicated how we are even connected to the 'main' company in CA, and our health insurance has always been seperate for the entire history the company has been in operation.

I thought it was wrong to, but that was straight from several people at oregons insurance commision's department - they said since the company's corporate office is in CA, and the policy was out of CA, CA laws applied :( I know in most all other situations it would he the opposite case, but they told me it's where the policy is purchased that determines what laws govern it. I'm still not totally SOL on it, because BOLI (Bureau of Labor and Industries) is looking into the policy, they have a division that regulates companies benefit packages and I've talked to them and mailed them all the policy info and all the documentation and other information I have about the whole situation, so it's possible something could come out of that. The lawyer I'm considering hiring recommended I try that route first, if BOLI finds merit in my complaint they could require the company to rectify the situation or compensate me, but if I go that route I'll likely lose my job, so that's something I have to take into consideration too. While totally wrong and illegal for them to fire me in retaliation for filing a complaint, the fact of the matter is my company is directly related to the housing industry and could easily 'lay me off' instead of fire me if they wanted to get rid of me.

It sounds like you're getting good advice. But keep in mind that a "lay off" is still a termination, just one allegedly not done for cause. And from what little I've read, a "reduction of force" of the one person who just happened to file an administrative complaint against them, should be enough to raise eyebrows all the way around.

Mike

I am sorry for this added stress and also for your boyfriends health problems. I agree with the other poster that sometimes how doctor phrases something may have a better chance of being covered. I also wonder if some treatments for rsd like nerve blocks or what ever would be considered surgery vs treatment though if it is for chronic pain then it may still be the dame. I hope you get some firm answers and of course that are in your favor

Absolutely Mike. My take on health Insuance industry is this, they are what they are, a for profit business nothing more and nothing less. Having 50 regulatory agencies in the US is the mechanism that allows these companies to increase their profits. Without it their profits would decrease. This is the reason why health insurance companies are exempt from anti-trust laws--- because of the existance of 50 regulatory agencies. If say, for example, there was only one regulatory agency, the fed, health insurance companies would no longer enjoy the anti-trust exemption and no longer able to game the system like they do now. Also state to state competetion would increase because they no longer would have a safe haven.

Don't get me wrong, I'm all for profit etc. but some estimates have placed 1/3 of total healthcare cost on insurance profits. This is not exceptable and will end in time because it will have to one way or the other.

Insurance companies...go figure!