I’ve brought this up several times now that we were eligible for open enrollment last fall, but it’s worth repeating because this past winter, we had one heck of a battle with our insurance company. It left me refusing medical treatment when my doctor thought I had pneumonia, and it left us wondering how in the hell we would be able to afford health care (in general) if things didn’t work out in our favor. I guess I should start at the beginning and tell you the whole story!
Last fall, we got an email from my husband’s HR department with a list of all the available insurance plans. We’d been on our existing plan since we got married, and my husband had been with this particular insurance company for as long as he can remember. They were our first go-to choice for a host of reasons: they’re widely accepted, some of our doctors *only* accept that insurance provider, and we felt a sense of loyalty to them since they’d been our provider for so many years. Additionally, they’re one of the only providers (that we were aware of) that carried fertility coverage. But, our premium was significantly increasing so we wanted to explore more inexpensive options. We started by making phone calls: first, to my OB’s office to see if I even needed to repeat fertility treatments (I did) and then to our insurance company to help us interpret our 2013 benefits.
This is where things started to get very, very confusing for us. See, in 2013, our insurance plan was drastically changing. Not only was the premium increasing, but they were doing away with co-pays altogether and changing the way the deductible and co-insurance system worked. They were also introducing a new incentive plan were you could incur “incentive dollars” for completing health tasks that would be put toward your deductible and out of pocket max.
Sounds simple enough… except we didn’t know how the deductible worked. Was it per person? Divided by the number of people in our family? I called customer service on several occasions and was given a different answer each time. Wasn’t it their job to interpret our benefits? My head was spinning.
On top of all the confusion, we weren’t sure if this insurance plan was the best fit for our family. I have asthma, for instance, and take Advair. One phone call to my pharmacy and I found out that the out of pocket cost for this particular medicine was over $400. We weren’t sure if we could budget $400 per month for this medication, when we were used to paying $35 a month co-pay in the past. And since we still had no idea how the plan actually worked, we didn’t know how long we’d be paying out of pocket for or when (or if!) the co-pays kicked in.
I eventually asked to have my call escalated to a supervisor and she reviewed the plan with me carefully. We spent quite some time on the phone with one another and I was given, what I thought, to be accurate information. Based on the information she provided, staying with this insurance plan seemed like a no-brainier.
I took careful notes every time I called our insurance company. I made note of the date and time of the phone call, the customer service agent’s name, and asked for a phone call reference number. In addition, each phone call was recorded (which is standard practice at our insurance company).
I went to get my Advair filled on New Year’s Eve, and I remember my pharmacist handing me a 3-month supply (something he’d never done before) and telling me he just saved me over $1200. My jaw dropped. What the heck was he talking about?! Their system had been updated with our new insurance information in preparation for 2013, and if I’d waited just one more day I would have had to pay the out of pocket price for my prescription. This was a HUGE red-flag and I came home fuming.
My husband and I called our insurance company on the next business day only to find out that all the information we’d been given during the enrollment period was incorrect. I spoke to a manager who pulled all of the calls I’d made and helped me file a grievance. She reviewed the information she heard on the calls and compared them to my notes, then confirmed that I was given incorrect information, even by the supervisor that I’d spoken to. She said we’d have a resolution within 30 days. She reviewed the correct plan information with me so we at least knew what our plan really entailed.
In the meantime, we were in limbo. We filed a complaint with my husband’s HR and OPM, but we also were not qualified to switch insurance companies since open enrollment season had closed. Our insurance company didn’t offer an immediate solution, either, so until a decision was made we had to use the insurance plan as it was designed.
Late last month, we were notified that the Grievance Team had determined that I was given correct information by a supervisor so we’d lost our case. They cited a specific date, and that was that. I was so angry I cried. First they admitted we’d been given wrong information, and now I was being told I was given correct information? Why were we given conflicting information over and over again by this company?
I reviewed my notes when I got home, and specifically looked for the time my call was escalated to the supervisor. This was the call when she clarified everything, and carefully reviewed all the information with me. This was the call I made that swayed our decision to stay with this insurance company. This was the call that was later proven to be incorrect, when I’d gone to pick up my prescription on New Year’s Eve.
I filed another complaint and we waited to hear back from the Grievance Team. In the meantime we started crunching numbers and trying to figure out how we were going to manage this financial burden we were now facing. It took two days to hear back from our insurance company, and this time they found in our favor. We were elated and definitely did not expect this decision!
We now have a letter in our hands stating their acknowledgement of their mistake, the stated resolution, and how our policy will work for the 2013 benefit year. It’s a huge weight off our shoulders. If I hadn’t been so careful in my note taking, I don’t know if this case would have been found in our favor. I was able to cite specific examples, dates, times and I even jotted down some exact quotations used in the conversations!
In the middle of this whole mess, my husband got two phone calls while at work from representatives explaining how our insurance actually plan worked. Neither of these representatives were aware that we had filed a grievance, and these calls spoke volumes to us. They told him that many, many people were confused on how their plan worked and it was their job to explain the ins and outs of the 2013 benefits. Interesting!!
Having to deal with our insurance company is something I’ve found that we have to do on a regular basis, especially when needing fertility treatments. We’re both very disappointed in what happened, and are left feeling dissatisfied in a company that we’ve been with for over five years as family. I worry that if I hadn’t kept such careful records, that as resolution never would have been found.
I’m glad to have this financial burden behind us, and this case found in our favor. We really are our best advocate!
Have you ever had an issue with your health insurance? How did you resolve it?