At the Mercy of My Medical Insurance

In all the companies I’ve worked for, we always gave group medical insurance. The only difference now in my 3rd company is that I have to pay for the medical insurance of my dependents. I have my mom and my sister listed as my dependents so I pay 2 premiums every month which are automatically deducted from my salary every salary cut-off.

The amount is pretty heavy to shoulder but it is fine since medical insurance coverage is far more important than the money that I use to pay for it. But we had quite a lot of unpleasant experiences with our new medical insurance and sometimes, it is not that good anymore as you have to worry a bit about how we’ll be covered instead of just worrying about how we could get better.

One noticeable premise on the contract between our company and the medical insurance is that our dependents have pre-existing clause. This means that when the dependent visits a doctor or a hospital for a condition that is already present before the insurance became effective, the patient will not be covered. Their definition of pre-existing is, may not be the exact words we heard, “pre-existing conditions are illnesses that are present before the insurance became effective or an illness that may have lied dormant but showed up during the effective date of the insurance”. We were confused.

The diagnosis of my mom was Hyperuricemia which is for high uric acid and we and the hospital staff read it as Hypertension (the doctor’s penmanship wasn’t clear). They contacted our insurance and they said it’s not covered since it’s a pre-existing condition. We told them that this was the first time my mom felt it and they said that it doesn’t mean that it wasn’t there before the effective date of the insurance thus, they won’t cover it. We were furious. Now that I am paying for their insurance, they would deny my mom coverage? I really wanted to get back at them but they said it’s the contract between them and our company.

There Goes the Pre-existing Condition

So we went to the cheapest laboratory since we knew it wasn’t going to be paid. Then, our doctor said, “This isn’t Hypertension, it is Hyperuricemia.” We went back to our insurance and told them it was Hyperuricemia and we have a certificate from the doctor that confirms it. So, we filed a claim. To our surprise, it was denied because the laboratory facility is not participating or in contract with the insurance.

That was way out of line. The one who reviews the claims didn’t seem to have reviewed the claim. They told us that we should have gone to a participating laboratory facility. It was unbelievable. We told them that we are under the notion that we won’t get coverage so we chose the cheapest one. The facility they were referring us to would cost us 400% more. Now they’re saying we should have gone to a participating laboratory provider? That’s just plain pathetic. So, we filed an appeal and I informed my company about it as well.

Another thing is that for Neurologists here in our country do not accept medical insurance out right. They demanded that patients with medical insurance should pay in cash first and then let the insurance company reimburse the cost. We thought, well that’s fine since it’s going to be reimbursed. So we paid the doctor and filed the claim (again, we shouldn’t be shouldering anything. We had peace of mind with our previous medical insurance). When it came back, again we were surprised. We were only paid 55%.

This is Just Too Much Already

What difference does it make if the Neurologists would accept medical insurance outright? They said those would be discounts. So there they have it. They’re discounts which mean no one should pay them. Why should we shoulder them? What about our Cardiologist? They paid for the entire charge. What’s the difference? They’re both specialists!?

For that I will be filing the appeal soon. Well, it isn’t really good to have a very complicated medical insurance where you won’t have that peace of mind that you could go to the hospital and get treated then the rest will be done by the insurance. I work for a medical insurance company and I know the workings so it’s a bit ironic that I have to deal with insurance coverage issues. Always try your best to understand how your insurance works and how you will be covered. Take care and stay healthy.

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