This Wonderful Insurance!

[airmechus]

:angry:
I was wondering if anyone has had a similar experience as this, and what they did about it:
When signing up for insurance in 2002 I chose the 100% coverage in network because of the 100% surgery coverage after deductable. My wife had gastric bypass sugery in Jan. of 2003 and in Aug of 03 I receive a booklet dated May of 03 capping the bypass surgery at $15,000. Now I am being bombarded with bills "exceeding lifetime benefits". This were never mentioned during sign up nor during pre-approval. I never would have taken thisinsurance knowing this and it is taxing our money situation with the givebacks and all. Anyone else having the same problem? If so, any suggestions? I filed an appeal with U.S.Airways benefits center which seems to never make it to BC/BS so I'm faxing another one myself.

HELP!!!!!!

 

[pitguy]

I would think if the surgery was done by a doctor that was "in network" that they would have to perform the surgery for the agreed fee 'limit' imposed by the insurance company. Always keep your states insurance commission or similar government office in mind for help. The anesthesiologist, medical facility or laboratory used may have not been in network.


--This is the worst insurance I have ever had.

 

[noname]

This is the worst insurance I have ever had.

I agree that this insurance plan we have is the PITs.

 

[Dark Cloud]

airmechus,
I sympathize with you. My wife and I retired and she was allowed to keep her insurance that she had at work ,as long as she pays for it. I have had so many problems with our (U's) insurance, that we didn't dare to drop hers. Honest to god, we pay $1,075. a month to keep hers. We just can't take the chance with just my
plan from U. No, that's not $1,075 a yr. It's a month. In fact just today I spent 45 minutes with my insurance, trying to get something straighten out with no help. We retired early and will be paying that for another 7 years. Yes our (U ) insurance plan "stinks". Good luck with your problems . Our prayers are with you.

 

[PITbull]

AFA argued this with management regarding specifically the "gastric by pass" surgery recently, and it was life threatening. In the NEW "summary Description Plan" that was sent to everyones home in August, outlines the "cap" on Gastric by-pass surgery at $15,000.

I say APPEAL IT, and get the documentation necessary to show that it was life threatening.

All groups are planning to challenge the Medical coverages. The unions have been meeting to exchange information on problems with coverages that we did not have in our old "plans".

Again, we never negotiatied or agreed to change coverages. We only agreed to help U with the contributions, co-pays and deductibles. ALL coverages were to stay the same as United Health Care. The summary description has not been amended since 1992. Mangaement had an obligation to send the amended summary descriptions to the employees during that time frame. THEY NEVER DID.

To bad, too sad. We will now challenge this.

Let your Local Representative know the problems you are having even with scripts. Make sure you write it up, not just call. We need "hard copies".

 

[BIGDOG]

JUST ANOTHER WAY USAIRWAYS AT CCY TAKES CARRRE OF THE WORKERS.

THEY LOWER YOUR PAY AND KEEP ON TAKING.

 

[jjdoe]

Airmechus, good luck to you. Make sure that you file your appeal within the timeline posted on the denial of coverage. Get documentation stating that it was life threating, etc. Attach that documentation with your appeal along with your complaint regarding the change in coverage. You need to be sure that your appeal is timely filed with the insurance company that is denying the coverage and that address should be on the denial letter in order to preserve your rights. Do not depend on phone calls to any company's benefit center. Appeals must be in writing. Make a copy of everthing you send. Send everything certified, return receipt requested so that you have proof of mailing within the specified time period. Additionally, some states have help available with situations such as yours through the attorney general's office. PA has a health care unit to assist in resolving insurance issues. If you live in PA, just access the website for the attorney general and find the health care unit link. There are forms online and a FAQ section. I just lurk here and on other boards but your situation was appalling. Hope this helps, it is just basically tips for fighting insurance denials in general.

 

[stewbear]

AFA argued this with management regarding specifically the "gastric by pass" surgery recently, and it was life threatening. In the NEW "summary Description Plan" that was sent to everyones home in August, outlines the "cap" on Gastric by-pass surgery at $15,000.

I say APPEAL IT, and get the documentation necessary to show that it was life threatening.

All groups are planning to challenge the Medical coverages. The unions have been meeting to exchange information on problems with coverages that we did not have in our old "plans".

Again, we never negotiatied or agreed to change coverages. We only agreed to help U with the contributions, co-pays and deductibles. ALL coverages were to stay the same as United Health Care. The summary description has not been amended since 1992. Mangaement had an obligation to send the amended summary descriptions to the employees during that time frame. THEY NEVER DID.

To bad, too sad. We will now challenge this.

Let your Local Representative know the problems you are having even with scripts. Make sure you write it up, not just call. We need "hard copies".

..PITBULL....what the HELL is going on, when I read that things we negotiated for are gone? This insurance debacle is the last straw. Where the hell are the attorneys for AFA when these contracts are signed?What is all this grievance ? Why didn't they NAIL the contracts down? We are serving meals on the planes without any additional help, we can't call off sick because we are so strapped it will put us behind for another month even when we have plenty of sick time that we worked for and saved. We have heard NOTHING from AFA attorneys regarding our plight. These people should be answering the many questions we have. The flight attendants are fed up with these conditions
By the way Where is THE MANAGER FOR INFLIGHT? With No answers, no solutions and nothing but negativity from everyone NOT FLYING AND DEALING WITH OUR CUSTOMERS. Will it EVER END? We have a tremendously dedicated work force that loves what they do...but we need communication, solutions, the tools to do our work and some leadership. The grunts(and damn proud to be one) are covering up for every thing and it is getting very old. Delta puts 36 757s in the air with a new name, state of the art entertainment and a new paint job in just a few months and we are pinny pinching on boarding music, inflight entertainment and cold food for 5 hr flights. And I thought Genie trays and the DC9 were tacky....

 

[Retired1]

I am retired and not 65 yet and retired prior to the CWA getting in. For my wife and i on option 3 the cost is 256.00 per month for medical. I got a letter yesterday saying my cost effective Jan1 would go to 305.00 which is right at a 20% increase. For anyone thinking what has the CWA done for me lately look at your rate and then look at mine. I think everyone has suffered a lot across the board but then to find out things have a cap when you use a preferred provider? I dont get it.

 

[Bradly71]

:huh: I just wanted to drop a little information in here to help you understand. I actually work for the largest Blue Cross Blue Shield Insurer in the country. I started a few months after my furlough from US.

I work in the customer service / claims department - so just to explain a bit. Insurance through Blue Cross Blue shield is not considered "fully insured" but "self funded". That means that all Blue Cross Blue Shield does is manage the money. The premiums you pay or are taken out of your check actually stay in insurance bank reserves that US must have set up. The claims come in to BCBS and are paid with their money, then every month US must reimburse BCBS for their expenses plus the service fees they are charged to do this for them. This is the part that is sometimes hard for people to understand. Since these plans are "self funded" they are actually not subject to many local insurance laws and guidelines as 99% of the time they apply only to "fully insured" plans. We own and operate the BCBS plans in 21 states and I deal with all 50 and have only run into the instance where that statement was incorrect once. I don't know where you live so I can't tell you for sure, but in most all states the Insurance Commissioner and/or Department of Insurance have no real legal force. They are more of a mediator and try to settle differences, however they can not impose any fines or force the insurer to do anything. Those types of things can only be done by the Attorney General in the state you reside in.

There are upsides and downsides to "self-funded" plans, unfortunately you are seeing one of the downsides. Since the funds are not put into any type of third party trust or investment but stay with the employer until claims are paid, they have more say in the matter. You are correct in the fact that you do have the right to appeal a denied claim after you have exhausted the complaint process. There is a time limit of 45 days from last letter of denial. So, as long as it has not been 45 days since you received your last Explanation of Benefits then you may still appeal. You would call the customer service number on the back of your card (should be listed with a claims address) and get the correct address to send your appeal to. The appeal process is done completely in writing for legal reasons and usually takes up to 45 days for a response to be sent.

*** Now this is the important part to understand*** Since the plan is "self-funded", US has the final say in what is and is not covered, what the benefit caps are, and what will and won't be paid. BCBS does negotiate with hospitals and doctors what are referred to as "usual and customary" fees and provides US or any other employer with the basic medical guidelines that they like to follow. However, your complaints and appeals after being reviewed by BCBS will be sent to the corporate HR office for final review. They must either approve or deny the request. If the request is denied then in most states the issue is over. Some states do allow you to sue the Insurance Company to force coverage however I have not run across any circumstances where that has been successful. You just need to remember to keep emotions out of your appeals as much as possible and provide all the documenation you can that shows it was morbid obesity and all conservative treatment methods failed.

I see you also mention the issue of "caps". Most health insurance policies do have either a lifetime or yearly maximum benefit. If it's yearly, then allowed maximum is usually in the $400K to $500K range. If it's a lifetime maximum, then it's usually in the $1Million to $2Million range. Services usually have some type of cap also, whether or not you use in or out of network providers. The amount you state that was allowed as the cap limit actually seems about average. Since I'm not mentioning specific claims or names I can say the most expensive one I've seen in the past few months was in the $20K range and that was due to complications durring surgery. This limits are usually approved by the employer as well. An in network provider can not balance bill you though, so you need to check on that. If your policy for instance says the allowed amount was $18K but had some type of in-patient surgery cap of $15K, then the provider can bill you - but only for the difference between the allowed amount and the amount paid by the insurer. You may want to go through all of the Explanations of Benefits you have recieved since treatment was started for this as it will usually show running totals on the bottom or last page. There also may be a benefit cap, which is usually the case. The policy may have a cap or exclusion limiting coverage for obesity to a specific dollar amount, so check that out as well.

I hope that maybe that cleared up how your coverage actually works a bit better. I'd be happy to answer more if you'd like or point you to more information.

 

[Retired1]

If you are retired dont bother to call for the New Summary Description Plan PITbull mentioned. She always gives good information but guess what. They dont have one for retired employees yet !!!!

 

[airmechus]

Thanks for the posts and support! I did mention a cap. but...it was added AFTER the surgery. That is my problem. I could have takem my wife's insurance last year if they were up front. Btw..Dark Cloud, you can call Kaiser's uncle once in a whaile you know!

 

[PITbull]

The Cap on Gastric Bypass surgery, is new to the Summary Plan Description. In the old SPD it was not covered at all and was looked at as cosmetic. But because Morbid Obesity is considered now to be life threatening disease, becaue of all the diseases associated with Morbid Obesity, Some insurance companys will cover this surgical procedure. Since U is "self insured" they basically set the coverages and use the guildines of what most insurance co. provide according to B/C B/S. When I am speaking about "life threatening", it must be for instance, someone is Morbidly obese and is in kidney dialysis. In order for them to be a candidate for Kidney transplantation, they need to drop 150 lbs. If they can not do this by conventional methods, then a doctor will recommend Gastric by-pass. This is the reason for the appeal process, to receive coverage payment to exceed the "cap". I am sure there are many other reasons as well. This is just an example.

As an aside, there are other issues with our medical coverages that were NOT discussed in negotiations. For instance, You enter the ER and services are rendered. Your booklet states that the hospital and ER our "in-network". However, many ER facilities sub-contract medical personnel THAT MAY NOT BE IN NETWORK. Therefore, we are finding out that many of U employees are receiving bills that exceed ER deductables and co-pays beyond what is described in our "in-network" booklets. Buyer Beware.

These are just a few examples of the egregious, misrepresentation of the new PPO plan that managment did not relay or convey to the labor groups who were at the table in 2002. Another example of "stealing" additonal cost savings. This will be challenged. If you have documentation of these kinds of occurences, please submit them to your local reps. All unions.

 

[N628AU]

Any time you have work done in a hospital, you will receive several bills. Often, your doctor may have surgical priveledges somewhere, and you are going to be billed by the doctor (in network), plus the hospital, anesthesiologist, etc. Often times your doctor is in network and everything else is out of network.

Don't fault US on this alone, this is a national phenomenon. Even in countries with socialized medicine such as Japan, many workers take out supplemental insurance to help deal with these costs.

 

[PITbull]

N6,

Don't give me that crap. I have worked in hospitals and with insurances for many many years. Don't even go there. We did not have these hidden costs in any of our other 18 damn plans.

So you talking about hypotheticals and conjectures, will not ease the mind, or make anyone feel that this is acceptable. IT IS NOT!!!!

This is not a phenomenon or a fact of insurance life. It denpends on the cost savings and how the plan is designed by the provider. AND WE DON'T HAVE SOCIALIZED MEDICINE IN THIS COUNTRY FOR WORKING AMERICANS.

Correction: I am not blaming management for the "plan", I am blaming management for its deception of the kind of PPO plan that they presented to the labor groups.