August 31, 2006 by bob.

Q. My health plan it work is going up in price to over $800 per month. I can just barely afford it now. I looked at a plan for $300 per month that includes a maternity benefit that we need. The problem is, it is an HMO and we would have to change doctors. What should I do?

A. The easy answer is, fire your doc.

Is that relationship so sacred that you are willing to pay $500 per month, over $6000 per year just to see him a few times during the year? I am sure you are comfortable with your doctor, but if $800 is not in your budget it is time to evalutate your priorities.

Have you considered going with the HMO and paying to see “your” doc out of pocket? Surely it would be much less than $6000 over the course of the year.

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August 29, 2006 by bob.

Q. I have mostly made up my mind to buy from a particular carrier. I had some conversation with the carrier and they turned me over to an in-house agent. He gave me a quote and sent me a link to complete an application. Should I go forward or deal with someone local?

A. Good question.

The in-house agent may have your best interest at heart or he may just be toting the company line. For sure, all he has to offer is that company’s product line. The company you mention does have some good products, and the one he recommended is probably the same one I would suggest.

As long as he stays with the company, and you are happy with your plan, there is nothing wrong with dealing with an in-house agent.

But how impartial will he be when it comes to disputing a claim? Will he be interested in fighting for your best interests or more conscious about preserving his job?

And how about renewals? Will he show you other options or only what that carrier has to offer? Will they be just as competitive next year relative to other carriers as they are this year?

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August 26, 2006 by bob.

Q. My health insurance was getting too expensive so I shopped around. I talked to several agents including one who spent a lot of time with me, explaining all the different options and showed me how the plan I had, and the ones I was considering, had a lot of benefits I would hardly ever use. By eliminating those items, I could save about 30% on my premiums.

Unlike most agents, he did not pressure me to buy on the spot. He answered all my questions and allowed me to study each plan option.

Yesterday he called to check in with me. I told him I had already bought from another agent who came to my home. He asked which plan and which company offered the plan. When I told him he said I had made a big mistake.

I explained that I checked out the company with the state insurance department and there were no complaints.

He told me I should have checked with patient billing at my doctor’s office and a local hospital. He said I would find that providers will usually refuse to accept assignment of benefits and will require me to pay them then file my own claim.

I think he is just angry I did not buy from him.

A. I think you are wrong.

The agent is not angry but rather is incredulous that you would buy from an agent that only had one company to offer and that company has such a poor product and reputation. He is correct. Most providers will NOT accept assignment and you WILL have to pay the provider then try and get reimbursement.

Rarely will the DOI make disparaging remarks about a carrier. The closest to that are press releases indicating a company was fined for a particular action.

If you want to know which companies do the best job of keeping your doctors happy, ask the billing department. Happy billing departments mean less headache for you.

I agree with the agent who tried to help you. You made a big mistake.

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August 23, 2006 by bob.

Q. I am looking for a plan that includes low copays, especially for Chiropractic and Dermatology. The plan needs to fit my budget. What is available for me?

A. Most plans will cover Chiropractic & Dematological visits . . . unless you have a chronic condition that requires regular treatment. In that case the condition would be considered pre-existing and would be excluded by a rider.

If you visit a Chiropractor more than 12 times per year, you can expect a Chiropractic exclusion rider. Your skin condition may also warrant a rider.

Low copays are nice but come with a price.

Given your pre-ex conditions, that may be ridered off the plan, you will probably come out better with a plan that does not include copays. The premium savings could offset the loss of benefits due to riders.

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August 21, 2006 by bob.

Q. All I really need is coverage for a large claim. The plan I have now has a $10,000 deductible is increasing the premium so I am looking for something less expensive but with more coverage. I found a plan with a $2500 deductible that is less money. All I really need is hospitalization coverage. I don’t need an agent, would rather shop on the internet. What is wrong with that?

A. Nothing is wrong with shopping around, as long as you understand what you are comparing.

The plan you have now has an at risk amount of $15,000 on a major claim. The plan you are looking at will pay about half your claim, if you are lucky, on a major claim.

A family friend was injured in a car accident in late May. Her bills so far are $680,000 and counting. Your current plan would have paid all but about $15,000.

The plan you are considering changing to would have paid $100,000. You would be responsible for the rest.

Still think you don’t need an agent?

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August 21, 2006 by bob.

Q. I want to offer health insurance to my employees. Not all of them, just some of them. One agent tells me I can’t do that, another says I can. Which one is right?

A. There are several ways to accomplish this, and a few that will cause you problems.

You can offer coverage to anyone you choose, as long as you do not contribute toward the cost of the coverage. You can offer coverage to all those who have worked a year or longer and not offer to anyone else. You can offer coverage to management employees and not rank & file. You can offer coverage to all that are over 6 feet tall and not anyone else.

All of these offers are acceptable (though not necessarily fair), as long as you are not paying any portion of the premium.

Once you pay a portion of the premium the plan is considered a group plan, even if funded with individual policies. When that happens you may run afoul of non-discrimination laws.

Some times agents will tell you to pick & choose the employees you want to cover, then “bonus” them the premium. I suggest you read all the documents you are asked to sign when you set up a list bill arrangement. One of the statements asked you to attest that you are NOT paying any portion of the premium, or bonusing the premium in any fashion.

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August 17, 2006 by bob.

Q. I have been working with an agent in Atlanta who tells me his insurance policy is better than any other in the market. There are no health questions and no deductibles. His prices are much better than what I have seen from others, including you. How is coverage so much better?

A. For starters, he is not a licensed agent. It is a simple enough thing to check with the GA DOI and learn quite a bit about the people who are pitching you.

If the person is licensed, you can find out if they are new in the business or have been around a while. You can also see what kind of course work they have taken as part of their required continuing education. And you can see how many carriers they represent and which ones have appointed them.

If this individual told you they are an agent, they are misrepresenting themselves. If they told you the plan was insurance they are lying. Both are illegal acts.

The plan you are looking at from this unlicensed agent is not insurance. To qualify for health insurance you need money and good health.

To qualify for the non-insurance, discount plan he is pitching all you need is money and the ability to fog a mirror.

A true insurance plan will cover you against major illness & accident and limit your out of pocket to usually $5,000 or less.

A discount plan has no limit on how much you pay. The $60,000 bill you just rang up is all yours, they won’t pay a dime.

See the difference?

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August 15, 2006 by bob.

Q. The rates you gave me in January are higher now. You also tell me the plan I wanted is no longer available. Now you tell me the carrier will exclude coverage for kidney stones. What kind of deal is this? Why did you change your offer.

A. Well, for starters, it is now August. Of course the same rates aren’t available just like gasoline is much higher now than in January (except for different reasons).

Some of the carriers have withdrawn plans that were poor performers. You should have snatched them up while they were available.

And . . . you didn’t have a kidney stone problem in January. When you passed the stone in March you just bought yourself a 2 year waiver (at a minimum) for kidney stone coverage.

Now what I have to offer is fewer choices, at higher rates, and less coverage.

This is what happens sometimes when you put off a decision that could have been made 8 months ago on better terms.

Kind of makes you wish I had been more pushy, right?

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August 13, 2006 by bob.

Q. I have been contacted by a collection agency over a doctor bill from 3 years ago that has not been paid. I assumed the insurance company paid this bill since I stopped receiving bills from the doctor some time ago. I don’t think I should pay this since so much time has passed. How can I make this go away?

A. So, let me see if I have this straight.

You were treated by the doctor, the doctor sent you a bill, you did not pay it, now you think you don’t owe the money.

Why would you think you don’t owe?

When services are rendered you are expected to pay, either at time of service or when billed. You just ASSUMED the carrier would/did pay rather than following up.

You should ALWAYS track your medical bills and match them against EOB’s. Failure to do so leads to these kind of issues.

Now the bill has gone to collections (that should tell you something) and your credit has been damaged. Continuing to ignore the bill will only make things worse.

If you want to make it go away, send a check.

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August 12, 2006 by bob.

Q. About 5 years ago I was diagnosed with high blood pressure & high cholesterol. My medicine has cured me but several insurance companies have turned me down. Why is this since I am cured?

A. You are not cured, you simply are controlling the symptoms of the disease with medication.

You have what is referred to as co-morbidity . . . two or more illnesses that can work in tandem to create a health condition much worse than either alone. Because of this, most carriers will deny coverage.

A knowledgeable agent may be able to assist in finding a carrier who will take you, but it won’t be easy. Whoever suggested you apply with the other carriers that turned you down did not do you any favors. That only makes your ability to find coverage even more difficult.

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