Insurance games: Word to the wise

By Darlene Sredl | 06/14/2016

I needed time to grieve and heal; they wanted detailed documentation.

Grieving woman

She’s a registered nurse and a licensed insurance agent and broker, but when her husband died and she needed to grieve, she found herself spending an inordinate amount of time justifying claims related to his care and life insurance policies.
Darlene SredlThe past months have been hard for me. First, Fred, my husband and best friend for 50-plus years, died 30 March 2015. Then, a heavy hailstorm pummeled and devastated the exterior of my home. Finally, one dark and rainy night as I headed home from work, a car crashed into mine. The driver kept on going, leaving me by the side of the road. He didn’t know if I was dead or alive.
Difficult as it was to surmount those catastrophes, my personal anguish was just beginning as I started the process of applying for healthcare insurance benefits. I didn’t anticipate having to spend time on paperwork. I needed time to grieve and heal. I ordered 14 death certificates from the funeral home and thought sending one to each company we had been paying premiums to would be sufficient. Was I wrong!
Two decades of premiums
My husband had purchased two cancer-related insurance policies and a long-term care policy, on which we had been paying premiums for 20-some years. As I sent out death certificates validating—I thought—my claims for benefits, little did I expect that I would have to prove everything related to each claim.
One insurance company required a hospital bill. Fine, I sent it to them. Then, they said that wasn’t enough. The bill would have to explicitly stipulate my husband’s cancer diagnosis, as well as the dates he spent in ICU, including the ICU room number. It is very difficult—in my case impossible—to get the medical records department of a hospital to alter its usual billing procedures to accommodate such a special request.
The fact that my husband actually died from a pulmonary embolism meant nothing to the company that held our accidental death and disability policy. Even though certification of my husband’s death conformed to the company’s written guidelines, the company rejected my claim because Fred suffered from other medical conditions—comorbidities. If a claimant has a condition that coexists with the one for which a claim is being made—arthritis, diabetes, COPD, cancer, etc.—it’s an easy way for an insurance company to get out of paying a claim and owe the claimant nothing. I wondered how many people who had taken out policies with that company suffered from comorbid conditions, especially if they were older?
I filed an appeal. It was rejected. When I asked the company to justify its decision, the representative said they needed more information. I was required to contact every physician and every other healthcare agent who saw my husband during the previous year and ask them—physical, occupational, and respiratory therapists—to submit statements about his medical condition. So I sent each a release-of-information authorization and personal letter asking for help in securing the information the insurance company was seeking. Again, my claim was rejected.
I filed a complaint with Missouri’s commissioner of insurance—who apparently doesn’t have the enforcement power I expected, because, once again, my claim was rejected. The amount of time an individual has to spend just jockeying correspondence is amazing. No wonder people wear out and give up. It is still difficult to fight “city hall,” as the saying goes.
Long-term care takes long time to process
Our long-term care insurer was even worse. With that company, a claim must go through many different departments, each taking upwards of a month to do its work before moving the claim on to another department. About halfway through the Big Stall, the company advised me that I needed to provide receipts for all medical services and personal care help, such as registered nurse, physical therapy, and occupational therapy services. This was a horrendous undertaking, as it required searching drawers, cabinets, etc., for year-old receipts I hoped I hadn’t thrown away.
In purchasing that policy so many years ago, Fred had—fortunately—purchased a rider for home care. Here’s how that rider works: For a “regular” long-term care policy, the claimant has to personally pay for the first 100 days in a nursing home or substantiate with receipts that 100 days of personally paid home-care expenses were incurred. At today’s nursing home/extended care rate of approximately $4,000 per month, that means the claimant has to shell out more than three months of care expense—roughly $13,300 out of pocket—before any insurance benefits kick in. Many very sick claimants who enter nursing homes do not survive those first 100 days, in which case the insurance company has the money you paid in premiums but owes and pays you nothing.
Fred’s wise move to purchase the 15-day home-care rider meant we only had to substantiate with receipts 15 days of home care expenses paid out of pocket. That’s what it says on the books, anyway. I have yet to see reimbursement of expenses for any of the home care-related professional services that were provided five days a week over a three-month period.
Also, I have yet to receive reimbursement for most of the personal care supplies— incontinent care products, medications, rentals such as oxygen equipment, Hoyer lift, and hospital bed—to which I am entitled. I did receive a check for $1,000, but the rest of the $4,500 I claimed was disallowed.
I asked about reimbursement of insurance payments I made to this company during the time my claim was in dispute. This was no small matter as I was billed for two quarterly payments totaling $1,000 during that period. I was told we hadn’t purchased a separate rider for that! How could they continue to take our money when they were aware that a claim was pending?
Full and complete?
Getting back to the accidental death claim: I finally received a check for $13.48. On the check was printed, “Full and complete satisfaction.” I knew if I cashed it, there would be no more opportunity to pursue the claim, so the check lays unendorsed in a folder on my desk waiting for its “brother” payment, the $15,000 death benefit still owed me. How many people would, in the same position I was in, unknowingly and unwittingly sign and cash the small check?
Of course, if reimbursement does not occur and the company continues its unscrupulous ways, I do have the option to sue. But it would be nice not to have that fight.
My purpose in writing this is not to wallow in self-pity, although, in truth, I have done plenty of that. No, for the sake of employees who have to contend with unwarranted claim requirements when they are grieving, or need to grieve, the loss of a loved one, my purpose is to alert nurse leaders—administrators who have influence in recommending insurance companies for inclusion on preferred provider lists—of stark realities and games that some insurance companies play.
Save those receipts!
When catastrophic illness strikes or an accident occurs, family members are often too preoccupied with their primary concern of caring for a loved one to think of saving and organizing receipts that may be needed later—often much later—by which time they may be irretrievable.
As people near retirement age, they also need to be aware, as I learned, that benefits listed in a policy are not always fully available. An insurance company can reject valid claims in so many ways. If a licensed insurance agent and broker like me cannot successfully navigate all the red tape, what happens to those who are less prepared? The insurance company wins, that’s what!
Not all insurance companies make filing claims so difficult. Many required only straightforward filing of a form along with a death certificate. Those companies, in my estimation, are the good ones, and they perform an important service at a critical time.
As I was finishing this article, my granddaughter Lauren called me. She said, “Grandma, I just had a dream, and it was about Grandpa. He said he was in heaven, and he loves us all very much. He said to tell you as soon as possible.” Tears of happiness started to fall like rain, and, finally, I grieved.
Darlene Sredl, PhD, RN, teaching professor at the University of Missouri–St. Louis, is editor of Evidence-Based Leadership Success Strategies for Nurse Administrators, Advance Practice Nurses (APN) and Doctors of Nursing Practice (DNP). A pilot, Sredl is also the author of two aviation-related books, Airborne Patient Care Management: A Multidisciplinary Approach, which addresses aerohemodynamics nursing theory, and Pilot Quest, a work of fiction that addresses the rigors of flight training.
  • retirement
  • rider
  • comorbidities
  • pulmonary embolism
  • long-term care
  • cancer
  • death
  • grieve
  • insurance games
  • insurance
  • Nursing Student
  • Nurse Researcher
  • Nurse Leader
  • Nurse Faculty
  • Clinician
  • Nurse Educator
  • Educator
  • ClinicalC
  • Roles
  • RNL Feature
  • RNL
  • Nursing Faculty
  • Nursing Student
  • Nurse Researchers
  • Nurse Clinician
  • Global - Oceania
  • Global - North America
  • Global - Africa
  • Global - Asia
  • Global - Middle East
  • Global - Latin America
  • Global - Europe
  • Personalization Targeting
  • Sredl_rotator_2Q16_SFW