Insurance, revisited

Well, the insurance issue still isn’t officially resolved yet but I’m feeling hopeful that it will all turn out in my favor.  That’s the short update.  🙂  I thought I’d go ahead and write a more detailed, coherent explanation of insurance and how it applies to me, since we all have such different insurance experiences in the USA.

When I last worked outside the home, through 2001, I was covered by Blue Cross/Blue Shield in a PPO plan.  I was an Administrative Assistant to the Human Resources Manager, and one of my duties was dealing with insurance.  I was the person who signed people up, handled the yearly enrollment meetings, removed people when they left the company, etc.  I explained the coverage to the new employees, helped people understand their EOBs (Explanation of Benefits forms, which are sent after the insurance company finalizes a claim) and would advise them when they had insurance woes.  Many times I would call the insurance company for them and try to work out payment issues.  We offered a few different plans – the HMO and PPO options of BC/BS (with HMO being the cheaper option), and a cheaper HMO option from Rush Prudential.  I saw firsthand how many people got tripped up with the HMO rules – seeing a specialist without a referral, etc.  Because of that I usually try to pick a PPO plan if I can afford it.  With those, you can see whatever doctor you wish but if your doctor happens to be a “Preferred Provider”, the insurance company pays more on your claim.

So!  I knew a fair amount about insurance, and I’m comfortable with the terms, paperwork, how claims are paid, etc.  When I was laid off from my job in 2001, I kept my insurance through COBRA.  It was horribly expensive compared to the small monthly premium I paid as an employee, but it was important to me to stay insured.  Once that ran out (I think it lasted for 18 months, or maybe it was 12 months) I had to look for individual insurance.  At this point I was working for myself so I had no group coverage to benefit from.  I used to compare rates and decide what coverage to go with.

Originally I applied for a plan through Blue Cross/Blue Shield since they were the ones who most recently covered me.  Imagine my surprise when they denied my application – I was considered ‘high risk’ because I took medication for my blood pressure.  Keep in mind, I never had any medical issues due to high blood pressure; it was something discovered during my most recent pregnancy and it just never went away after I had Paige.  I lost a lot of weight and ate right, and nothing affected my blood pressure, but it’s something that runs in my family (along with high cholesterol) so the doctor put me on medication to keep it down.  So I take my medicine, never have any problems…and I was still denied insurance.

The way it worked when I worked outside the home and needed insurance through my employer was pretty simple.  You fill out a basic form – name, address, birthday, social security number, etc.  I can’t remember for sure but I believe they ask if you smoke, and maybe ask your height and weight but I think even those small details are left off the form.  You just give them basic information, mark off which coverage you want, and whether you have dependents.  You’re automatically enrolled, no questions asked.  Once a year there’s an enrollment period (usually in October) when you can switch plans, again with no questions asked.

As an individual, paying WAY more in a monthly premium, things are different when you apply for insurance.  You’re asked to list every doctor visit you’ve had in the past 10 years, all hospitalizations, all medications taken (plus when they were prescribed, what for, etc.).  Your whole medical history is scrutinized before an insurance company will insure you.

So when I applied for another plan, I’ll admit I was tempted to leave off this incriminating information just so they would cover me.  I couldn’t do it though – it just scared me too much to omit information.  So I was honest again, this time applying with Unicare, and figured I wouldn’t be accepted by them either.

Happily though, they accepted me and things were just fine.  So from about 2002 or so up until December 2007, I was covered by Unicare’s PPO plan.  Things went as usual – I almost never see the doctor except my once a year “womanly” checkup and my annual visit to my doctor to check blood pressure and cholesterol.  I take cholesterol medication now as well, and all of my numbers look really good.

Every year my premium went up, quite a lot.  I would switch plans within Unicare so that I had a higher deductible, to make my monthly premium more affordable.  When you do that, though, you can’t switch back to a plan with a lower deductible without going through the whole application/underwriting process all over again.  So it was a big decision to keep increasing my deductible, knowing I would be stuck with it from then on in.

In December I got a letter that my monthly premium was going up to around $220 a month.  This was for a PPO plan with a $5,000 annual deductible (the highest they offered), and a separate $500 deductible for prescriptions.  The plan I was on would let me see my doctor 3 times a year, with a $30 co-pay each time.  If I saw the doctor more than that, then I paid full price and it was applied to my deductible.  I would need to spend $5,000 of my own money before any claims were paid, and frankly, that sucked.  Plus, they didn’t cover my annual physical with a co-pay.  All the lab tests, mammogram, etc. went to my deductible and I paid the “negotiated rate” that the insurance company had with the health provider.  I was paying a lot of money for peace of mind and not getting a real lot back.

So although I didn’t have much time to research a new plan, just about two weeks to research, apply and hope I was accepted, in December 2007 I decided to look for cheaper insurance with better coverage.  Most plans look good until you see how they cover prescriptions – they either don’t cover them at all, or they charge a huge separate deductible for prescriptions.  Finally though, I settled on Aetna.  They seemed to really promote preventative care, with great coverage for mammograms and annual physicals, and since that’s really all I ever used insurance for (besides my monthly prescriptions for blood pressure and cholesterol), I crossed my fingers and applied.

Well, they too were cautious when they saw my medications listed, and I had to give lots of extra information to the Underwriting department before they accepted me.  I had to give the results of my most recent cholesterol test and all kinds of other details.  They did accept me but with a higher monthly premium than I was originally quoted.  I have a $5,000 annual deductible and $500 separate deductible for prescriptions, but my premium (even at the higher rate) was MUCH more affordable and my preventative care would be covered either with a co-pay or at 100%, so I was thrilled.

When I applied, there was a question asking if I’d seen a doctor for “any of these issues” within the past 10 years, and hearing loss was listed.  I answered “No” because my last hearing loss-related visit was 15 years earlier.  I hadn’t even had an audiogram in the past 10 or 15 years – my hearing loss was just not a medical issue at all.

That’s what had me SO freaked out about this letter I just got from Aetna.  I was afraid they thought I was trying to hide my hearing impairment from them, even though I answered truthfully.  Plus, I’ve heard so many times about people having their insurance coverage canceled because they left off one innocuous doctor visit on the application, so the insurance provider says they lied or omitted information and cancels their coverage retroactively.  Sadly, it happens to many people and is legal.

I got that letter, with the vague questions which sounded like the insurance company was trying to trap me into lying to them or leaving information out, and I completely lost it.  It wasn’t even possible to answer the questions they asked, since there were no time frames given and none of the questions were specific.  The only one that I could answer was “What is your current height and weight?”

Here’s how my mind works in a situation like this:  Oh my God, they’re going to cancel my coverage because I answered “no” to that question.  I am going to owe over $300,000 for all the money they paid out this year.  I don’t have that kind of money, so we will have to declare bankruptcy.  We’ll lose the house.  I won’t be able to get any insurance coverage now because it will look like I committed insurance fraud.  I’m so stressed out over this that I’m going to have a heart attack.  (I couldn’t sleep – all I did was lay in bed and worry.)  And if I have a heart attack, what hospital will take me if I have no insurance?  How will I pay the bills afterward?

On and on.

Of course, I had to wait until Monday to even begin to figure out what was going on, and I got the letter on Saturday.  It was the worst weekend I’ve had in many, many years.

On top of all this, the letter from Aetna said they couldn’t pay any of my claims until this was resolved.  I was panicked about that too because I just had my annual checkup, so I had claims in for my doctor’s visit, mammogram, lab work, etc.  I also needed to renew my cholesterol medication this week, and it costs about $95 a month if I have to pay in full (it’s $25/month with a co-pay through insurance, after I meet the $500 deductible).  So I was afraid to renew my medication and figured they would reject all my recent doctor bills.  Ugh!!

Dave was able to get through to the Aetna underwriter on Monday of this week.  She apologized more than once for the vagueness of the questions – I guess it’s kind of a form letter that they use.  She said mainly what they are looking at is the date of my recent hearing loss – they want to confirm that it wasn’t before I applied in December.  I can see how it looks so suspicious – I apply for new insurance in December which goes into effect in January, and then four months later I go completely deaf … and get surgery for cochlear implants in July.  Anyway, she said based on the records she had so far she didn’t think it was going to be a problem, so I started to relax just a little bit.

The next day, election day, we got a phone call from the company in charge of going over my medical records.  They wondered if they could fax the medical release forms to me, so Dave gave them our fax number.  We got the forms, filled them out and faxed them back that afternoon.  There was a form for my regular doctor and a form for my ENT/surgeon who did my cochlear implant surgery.  Both asked for my medical records for the past two years.

That was a BIG relief because I haven’t seen my ENT at all in the past two years other than once I went deaf this year.  My first visit to him in 2 years was in mid-April 2008 when I lost my hearing.  My regular doctor has seen me once each year for my annual checkup, and those visits were reported on my insurance application.

Dave faxed a letter to the Aetna underwriter on Tuesday as well, with the medical release papers, asking if she needed any more information from me.  All the vague questions they asked in their form letter are answered in my medical records, so I didn’t specifically answer the questions (which would have been kind of impossible anyway).  We haven’t heard from her, but the medical records company called and left another message today.  Dave called them back and get this…they were calling to ask about the medical release forms and if they could fax them to me.  Dave said we already did that, they put him on hold and then came back and said, “Oh, sorry, it looks like we got them on Tuesday.”  What the hell?!  I feel like incompetent people hold this huge decision in their hands.  It’s not very reassuring!

I am cautiously optimistic though – I did bite the bullet and submitted my prescription renewal today and it went through, covered by insurance.  I checked my claims page on Aetna and they paid my mammogram yesterday.  So maybe things are okay?  Either that or it was just an empty threat about them not paying my claims until this is resolved.

I figure, if they really try to push this I have a legal leg to stand on and I would definitely take them to court.  The underwriter did tell Dave, though, that this was not a case of recission; however, my monthly premium will probably go up about 25%.  So right now I’m just generally tense, not hysterical.  I won’t completely relax until I receive a letter from Aetna saying the issue is resolved and I’m not canceled.

Finally, I had my 3 month mapping session today.  I almost cancelled it, because it’s $275 an hour if I have to pay full price, and I didn’t think my insurance would cover it.  We decided, though, that we would just pay if we had to because it’s too important to ignore.  I will save that for another post though…as always, I talked too much.  But hey, insurance issues apply to many of us so I thought it might be helpful for someone out there.  Or just give all of you with good insurance a reason to breath a sigh of relief and think, “Thank goodness that’s not me!”  LOL

THANK YOU many many times over to everyone who left encouraging comments, sent nice emails and sent good thoughts my way.  It means so much, I can’t even begin to say.  You all are great!!  🙂


About wendiwendy

I'm a real-life bionic woman.

Posted on November 6, 2008, in Cochlear Implants & Hearing Loss and tagged , . Bookmark the permalink. 6 Comments.

  1. Hang in there Wendi, you have a lot of people pulling and praying for you! Keep the faith! Good things happen to good people.



  2. Hang in there! Insurance issues are a pain in the butt. I’m going through one myself!


  3. I am relieved for you. I am sure things will work out. I prefer PPOs to HMOs myself and you are right, COBRA is 18 months. I remember that after several layoffs from my previous employer, but I was never laid off more than 3 months at the time, so I never lost insurance coverage. I am thankful to be covered under Hubby’s group health plan even if it’s UHC.

    Health insurance is crazily out of control. I was paying $125 a month in 2003 until I had to take a severance package. I am sure Hubby’s paying about $175 for a family of four, including a separage dental premium. But without that negotiated system that insurances have with participating health providers, it’s costly.

    Hang on tight. Well, on second thought, you don’t have to hang on too tightly anymore. 🙂 I can’t wait to hear more. It does sound like they are letting the latest claims through. 🙂


  4. I just know everything will work out OK. You’ve done everything right and you know your stuff! Please keep us posted on this!!


  5. Whew! Wendi! Sounds like you can breathe a bit easier. Let us know when it is all resolved and you can take full breaths!

    Jennifer 🙂


  6. Wendy –

    I hope all ends well with your insurance situation. Any hesitation by an insurance company can be very stressful, and it happens all the time. They are causing a lot of extra stress and illness by their actions. Their employees must either be incompetent or get bonuses for inventing ways to delay or reject a claim.

    You mentioned having surgery for implants (plural) in July. I just had an implant last month. It has opened up a whole new world of sound. I haven’t heard of any insurance company covering implants for both ears. I guess they figure that if you can hear in one ear, you are no longer deaf. If you had bilateral implants and Aetna covered both, you should be very happy indeed.

    Best wishes,



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