Avoiding health insurance headaches

Crystal Engle like any mom wants to be around to see her children grow up, something her mom didn't get to do.

Crystal: She was diagnosed with colon cancer when I was about 9 and a half ten years old and she passed away when I was 12 years old.

APPEALING A CLAIM?

On Your Side Ways to Do it Right according to the Virginia Bureau of Insurance

Keep good records
Write down the date and time of calls
Get the name of the people you inquire with
Note what was said in the call
Keep photo copies of any letters you send

Be patient
First try to resolve the situation on your own
Sometimes a mistake has been made
It may be corrected as soon as you inquire

If your complaint isn’t addressed Contact the Bureau of Insurance
Monday-Friday
8:15 a.m. to 5 p.m.
1-800-552-7945
You may be instructed to file your complaint in writing

Bureau of Insurance will
Investigate your complaint
Help you get a clear response to your questions
Correct misunderstandings

* The Virginia Bureau of Insurance received a total of 301 requests for appeals for calendar year 2007 and so far, it has received 112 requests during 2008.

MAKING AN INFORMED BUSINESS DECISION

On Your Side Ways to Do it Right from the State Corporation Commission

Educate yourself Learn about rates, fees, and other terms before making a financial decision. Read the fine print, ask questions, and don’t allow yourself to be rushed.

Shop around. Not every company offers the same product for the same price.

Beware of pie-in-the-sky offers. Make sure an insurance, banking, or investment product is legitimate and is right for your needs.

Deal with companies and individuals that you know and trust. Contact the SCC ahead of time to see if an insurance agent, insurance company, investment advisor, stockbroker, bank, mortgage lender, or payday lender is authorized to do business in Virginia.

Get any offer or agreement in writing Be sure keep a copy for your records. Know your rights and responsibilities and where to file a complaint in the event of a problem.

Check your credit. The information in your credit report can make a difference when you apply for credit, insurance, or a loan.

Crystal's mom died at 40 of colon cancer. Because of that, two of her doctors said she needed a colonoscopy screening at least ten years before she turns 40. She's 31 now, so by that standard she is already a year late.

Crystal had the colonoscopy in November of last year. She says she was surprised when she got two letters in the mail, from Anthem, one on November 15th and one on the 16th saying she owed 700-dollars. After three months of dealing with the claim, Crystal contacted 10 On Your Side. We wanted to help Crystal sort this out so we contacted Anthem's Scott Golden who came to Roanoke to answer our questions.

Scott Golden: In situations like Ms. Engle's, benefits fall into a gray area it's not black it's not white and a lot of them fall into these preventative tests like this.

We found her policy says a colonoscopy is only covered for people 40 and older.

Crystal: They said no you'll be fine and I said well I know that the insurance requires me to be a little older and they said it shouldn't be a problem. You'll just have to have your doctor send a letter stating the reason they want you to have this done.

Golden says this has nothing to do with Anthem, that her policy is controlled by an insurance company created by the state of Virginia called Local Choice.

Karen: If she had gone to the state of Virginia then perhaps Anthem could have been left out all together?

Golden: Very well could have been.

But Crystal says she contacted the state at the end of January and got a letter back on February first, saying she needed to appeal with Anthem first She says she had already tried that. Golden also told me she should have had her doctor contact anthem's doctor on staff directly to discuss it.

Crystal: There can be no doctor to doctor and you are going to be responsible for payment

But Crystal says she asked if she could have her doctor call Anthem's doctor during a phone call on February 6th and they said no. After 20 to 25 conversations over the phone and in letters Crystal pushed harder.

Crystal: That is when I started to get really frustrated because I thought to myself, well my doctors told me to. And you feel like you ought to listen to your doctor.

Where was the communication breakdown?

Dr. Eric Swisher: Sometimes there is no right answer. I think in this case there is a very clear right answer.

Crystal: I understand that they have to have policies but there still ought to be a chance for you to say okay I have special circumstances.

Karen: What can be done to prevent the debates patients like Crystal have to go through?

Golden: I think a lot of it is about education. You wouldn't walk out and buy a car without doing research. I think the same needs to be done with health plans.

Karen: When they said you can't appeal it how did you feel?

Crystal: I really felt mad because I felt like I had done all the right things and listened to my doctor and called the insurance company asked the questions and it really upset me that they didn't feel like I could even appeal it...

Ultimately, the day we went to interview crystal she had just gotten word that all but 70 dollars of her bill had been paid.

Karen: What did you think?

Crystal: Then part of me didn't know what to think because I didn't know what really pushed it over the edge...that now they were willing to pay for something that for three or four months they had been saying no, no, no.

Now, Crystal has the relief of knowing she is colon cancer free but her doctor has recommended another screening in five years. She will still be under forty and says she dreads going through this process again and hopes it will be less complicated then.

We have found it likely won't be as complicated because Walt Norman the program manager for Local Choice tells me that beginning July first of this year, they will completely do away with age requirements for screenings, like the colonoscopy Crystal had.

He says, Crystal never should have been told she could not appeal a claim denial. He also says it has never been their intent to not pay claims that are justified.

But he emphasized that it is important for patients to read their insurance workbooks carefully and follow the exact process outlined in those policies.