TheInsuranceWarrior.com Health insurance help.
The Insurance Warrior
Between 2000 and 2003, seven in ten adults who were driven into debt by medical expenses HAD INSURANCE AT THE TIME" (Readers Digest, April 2006).
In other words, you are more likely to face financial ruin from medical expenses if you HAVE health insurance, than if you do not have it.
You Are All Uninsured
This site was created because times have changed over the last thirty years. During the late 1960s, health insurers became acutely aware that healthcare costs were skyrocketing. In their infinite wisdom, the actuaries and bean counters came up with the concept of “managed care.” Sounds friendly, doesn’t it?
Managed care means “managed costs.” In order to manage costs, care is limited and/or denied. In order to control costs, your doctor is now employed by (or contracted with) the insurance company, and they get to dictate what type of care he prescribes.
Obviously, managed care has been a dismal failure both in terms of delivering adequate care AND in controlling costs. Care for even the most common cancer is scary-expensive. So, unbeknownst to you, the health insurers have instituted hundreds of ways of not paying for your care. They even have a word for this industry-wide practice: Cost Shifting. The costs are shifted from the insurer to you. Big costs.
What Can You Do?
Arm yourself. You must become an Insurance Warrior.
I became an Insurance Warrior in 2005, when I was diagnosed with appendix cancer. There is a curative treatment for appendix cancer – a meticulous fifteen-hour surgery combined with intraperitoneal chemotherapy. It was not offered in the insurance company network. So, they told me to go home and die. I did not take kindly to this.
In practice, it was more insidious than that. My various in-network doctors did their utmost to discourage me from even considering any treatment, saying ...
“There is no treatment for your disease.”
“If you get surgery from Dr. S. (the world’s expert on appendix cancer), you will be disabled.”
“You don’t have cancer; it is benign.”
Remember, the doctors are the gatekeepers for all medical services. True curative treatment for my cancer might be very expensive, and it was not offered by anyone under the control of the insurance company. So, they would say anything to stop me.
I was so offended by this approach that I found the world’s expert on my cancer, then beat up the insurance company until they decided to pay every penny for my care. Then, I went on to do the same for everyone who was asked me to help them. Together we have defeated dozens of insurances companies, forcing them to pay for lifesaving care, making them do what is right.
Insurance Warrior 101
This is a quiz. What is the ONE power we have to make health insurers pay? Answer: The power to sue them.
We are not going to sue them. It would take years, we couldn’t afford it, and we probably wouldn’t win. We are just going to INFER that we are a very dangerous opponent, we might possibly be a lawyer, and we would have a very powerful case if we did decide to sue them.
Health insurers are not accustomed to their customers fighting this terrible shifting of costs. We are sick, we are scared, we have lost our jobs due to illness. The best possible scenario from a cost-control standpoint is that we die – and soon. If you put up a reasonably good fight, they will always pay. When they cave in and do what they should have done in the first place, guess what they will call it? A “goodwill payment.”
Your Battle Plan
It is your insurer’s job not to pay ... nothing personal. It is your job to make them pay. In order to make them do your bidding, you must turn yourself into the person most hated and feared by insurance companies: THE LAWYER. Or, in your case, the pretend-lawyer.
- Remain calm and professional at all times.
- It is not fair. They are trying to deny you the treatment you need. It’s not fair. Have a major session with yourself, then get over it. Hollering and screaming won’t get you anywhere. You must maintain your composure if you plan to beat them at their own game.
- Document everything.
- Every phone call, every doctor visit. As soon as the health insurer realizes that you have something expensive, they will mobilize their forces to not pay. From that moment on, everything they do and say is material for your appeal.
- Put it in writing.
- Many have spent weeks and months haranging their health insurer on the phone, trying to persuade them to pay. This will never work. Why should they pay, just because you asked them to? The job of Customer Service is to make you go away. And the way to move beyond the front lines is to: Get a determination in writing, then appeal it in writing.
A Successful Appeal
A successful is a powerful legal document, designed to put your insurer on notice that – if they do not do what you want them to do, you will SUE THE LIVING PANTS OFF OF THEM.
The elements of a successful appeal:
- Your treatment story
- Include any and all details that show how badly they have botched your treatment. You want to sound like such a medical mistreatment hot potato that the only thing left for them to say is “Where do we send the checks?”
- Facts
- No hysterical stories, no pleading how unfair this is. No feeling words. This is all about you, calmly proving that they HAVE to pay. Have they ruled that your treatment is experimental? They have no proof of this, but you can easily amass journal articles and studies and quotes from various official agencies proving that your proposed treatment IS accepted, proven, and standard of care for your disease.
- Their own words
- If you talk to doctors, bureaucrats, customer serice representatives at the insurance company long enough, they will say plenty of ridiculous, untrue, contradictory, actionable things to you. I guarantee it. Quote them.
- Their own objections
- Overcome them. Your case is based on your insurance company’s objections. Let’s say they determine that your proposed drug/treatment/surgery is “not medically necessary.” All this means is that they don’t want to pay. Go to your benefits booklet and study every word in their definition of medical necessity. Then prove that your proposed treatment fits every single clause of their definition. Beat them at their own game.
Address your appeal to the correct decision-maker, with carbon copies to higher-ups at the insurance company who will check up on them. Then, call them every day and ask politely if they have received your appeal ... insurance companies have an amazing ability to lose faxes and letters.
Be relentless, be dispassionate, be cool. Prove your case, then push it through the bureaucracy step by step.
When you emerge from your time of Medical Trouble, not only will you be in the best health you can be, but you will be at peace, knowing that you did your utmost to save one precious life.
Discussion
Featured Page Nomination
TheInsuranceWarrior.com was formerly nominated to be a featured wiki page. After a few months of discussion (see below), there still needs to be work done on the page. If you plan to work on this page and re-nominate it to be featured, please do the following:
- Copy {{:TheInsuranceWarrior.com/FeatureDiscussion}} and add it to the relevant section on Under Discussion page in alphabetical order.
- Edit this page and replace {{FeatureMeOld}} with {{FeatureMeCurrent}} in the discussion section.
- Added to nomination process on 5 June 2007, from an old nomination that hadn't been processed.
- An interesting place for discussion. This WikiPage makes an argument that is well thought out and makes some points. The page itself seems a little dry though. I just made a few SuggestedEdits trying to format the page a bit better, which I think helped, but it's still dry. -- TakKendrick
- Removing nomination. No edits from the webmaster since March. Obed Suhail 04:50, 27 December 2007 (PST)
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