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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August 11, 2006 by bob.

Q. I have double coverage, my plan through my employer and I am also covered under my wife’s plan at her work. I have recently been diagnosed with early stage cancer and I want to pursue a treatment that is not recommended by either HMO. What can I do?

A. My first question is, why do you have double coverage? Unless both plans are available at no charge there is no reason to maintain two major medical plans.

You didn’t say why the HMO denied the treatment plan, so I have to assume they know more about your situation than I do. Despite the “bad rap” many HMO”s get in the press, they actually do a very good job of disease management. In many cases, even better than most PPO plans.

Unless you or your wife are an oncologist, they probably know more about what works in your situation than you do.

You do have several courses of action. The easiest is to allow your carrier(s) to map a treatment plan and minimize your out of pocket costs while taking advantage of their expertise.

You can appeal, and delay treatment. The appeal process is time consuming and waiting may cause your situation to worsen, decreasing the likelihood of a positive outcome. It may also leave you back where you are now.

You can pay for your treatment out of pocket while appealing. Keep in mind your appeal may still be denied in which case you have paid thousands for a treatment that would have been covered in full, or close to that, had you listened to your PCP.

If your appeal is denied, you can take it further to the state DOI. You may also want to consider legal action against the HMO.

All of these are costly, time consuming, and rarely have outcomes to your advantage. I might add that several studies have indicated that stress can affect the outcome in treating some illnesses.

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August 11, 2006 by bob.

Q. Why won’t company’s allow me to get the coverage I need? I am on regular medication for high blood pressure and high cholesterol. Every company I have applied to will not allow me to have a drug copay card, or will not cover my medications.

A. The answer is two fold.

You probably applied to the wrong company.

The carriers are not stupid.

Some carriers, but not all, will allow you to “buy up” your coverage by paying extra to have coverage for some pre-ex conditions. In these cases, you can have the coverage you want. The person that advised you to apply with a particular company was either uninformed or simply gave you poor advice.

And some medications, particularly those for cholesterol, are quite expensive. Carriers will not write your cover for $200 per month knowing they will have to pay out $400 or more in medication costs.

There are ways for you to offset your out of pocket costs for meds. One is with an international pharmacy source. Another is to look at some of the PAP’s (Patient Assistance Programs) such as those outlined here.

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August 10, 2006 by bob.

Q. My child is attending college in another town and I have her covered under my employer group plan. Is this sufficient coverage or should I take out the plan offered by her college as well.

A. Most likely the plan offered by her college is minimal coverage and is unneccesary as a supplement to your group cover. In addition, her student fees probably cover most, if not all visits to the student clinic.

I would suggest you consider applying for her own policy, separate from your coverage. There are many things that can happen to affect her eligibility under your plan. Also, you may be able to find sufficient coverage for about half the price you are paying now.

Most students rarely visit the doctor and really only need a high deductible plan without copays. Many times you can pick one up for less than $80 per month.

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August 10, 2006 by bob.

Q. I was laid off from my job on June 16th. The following week I went to my doctor. Now I am told I did not have insurance and must pay the doctor for the office charges. I thought I had coverage until the end of the month through my group plan.

A. What you thought doesn’t count . . .

Some plans extend coverage through the end of the month. Others give you to the end of the month and then another 30 days afterward. And some plans stop the last day you worked.

If your plan is governed by COBRA (or a similar state law) you would have the right to convert your coverage provided you paid the premium.

If you have not found replacement coverage you should consider no less than a STM (short term medical) plan such as this one.

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