The Jubber Journal

sharing snippets in random sequence from my life


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Have you ever taken a moment to read through your insurance policy to establish what is and isn’t covered?

I think most of us don’t bother reading the fine print until you actually need to seek treatment and there you soon discover what you will be paying for and what your carrier “might” cover when claims are submitted.

Has anyone fallen victim to the infamous “pre-existing condition” clause? This is one of the most criminal aspects of fine print in any health insurance contract. I signed up with my carrier in June of 2007, and later in the year needed to use my insurance, only to have every single claim related to my diagnosis rejected because of this clause. What is amazing is that you continue to pay your monthly premium, as well as the deductible and then start grappling with the endless bills that are rejected by your carrier, and require payment by the service provider – bit of a vicious circle.

The next little surprise being in or out of network! So…let’s look at this for a moment shall we;

Hypothetical scenario – you are taken to the ER, and have all these bodies milling around you, drawing blood, taking ex-rays, administering medication, you get the picture. Insurance covers some services and abandons others, and on your statement they thank you for choosing an “in- network-provider”, which is usually the lessor amount, and then the massive figure in the far right column is denied and you are liable for the claim because it was a service rendered “out-of-network” – genius bait and switch don’t you think?

So…that was hypothetical, right? But what happens when this actually happens and you are told that the service provider that drew your blood every 6 hours is not covered by the “network”, and that you have to settle the claim, plus pay your deductible, and your monthly premium! Do we have a choice when services are rendered in an Emergency Room situation, where patients are usually incoherent and unable to make informed decisions? Does it mean that we must first interrogate all service providers before allowing them to administer care? If so, how do we do that? Carry a massive three inch binder listing all the service providers throughout the county, who is in-network and who isn’t? Seems a bit of an oxymoron to me! Maybe it is easier to walk out of the building, cross the street and lay on the pavement – that might get you into the correct ‘Network”.

Once you have satisfied your deductible, and your insurance decides that they will actually pay for some of the services rendered to nurse you back to health, take a look at the statement. If you were fortunate enough to have claims paid, you will noticed that the original invoice from the service provider is usually astronomical, and when your carrier settles it is usually for a whole lot less. However, if you are unfortunate, and the service is out-of-network, you won’t have the ability to negotiate with the service provider, and will be saddled with monumental never ending bills that set the path to ruining your credit.

I wonder who decides who is in which network, and as patients what rights, choices and options do we have and are we entitled to, in order to ensure that we are covered by the “network” and don’t find ourselves crumbling under the financial burden of settling bills that we truly had no idea were out of “network”.

Because I have been a victim of the aforementioned scenario, I can honestly say that to me the system is flawed, it is a brazen way for these corporations to make millions of dollars and shirk their responsibilities especially when we need the service, and is a replica of mafia style business operations. I sincerely wonder how much this new healthcare bill will change or alleviate the kind of nightmare families face when dealt a medical blow that certainly has the ability to take them out of the race.

We hardly ever pay attention to some of these details, until we are faced with them.

Author: Vic J

Living a simple life, free of clutter and complexity.

One thought on “Networked..?

  1. That is so not right! …. America has the best health care in the world ….with a worst process of paying for it. A system that does not work for so many hard working people. I am definitely not a supporter of the Obama bill, but health care policies need to change. What you described sounds underhanded at best and borderline criminal.


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