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A Family Story

This is not so much an article about access to health care as it is a description of what can happen to nearly any family in the health care system in America today.

Among the pitfalls that anyone can fall into are a myriad of gotcha situations, any one of which can be hazardous to your financial health as well as your physical health.  This article describes real experiences that my family had that may or may not apply to a situation that you might encounter in your home state.

While the story is true and some of the events might happen to you or your family member, the fact is that the cracks that one can fall into are many and varied.  The only thing that can be said with certainty can be that you do not want to get seriously ill in America.  It could be hazardous to your financial health.

The situations that led to our predicament were and still are complex.  They are from my view unnecessarily so because of some governmental regulations that applied to my situation, creating a kind of "perfect storm" scenario that could not have been navigated by nearly any person who suffers from mental illness.

The situations were compounded by my accepting an offer to get bought out of my existing business and needing to start a new business.  Interestingly, my daughter who suffers from schizophrenia was not the original problem, my other daughter who has asthma was not even accepted under the individual health plan that we needed to purchase and needed to exercise a health care portability program.

Problem one started when we had to buy a portability plan for daughter number 2 that meant instead of getting a single health plan, we had to pay for two separate plans at an even greater cost.

Our problems were only just beginning.  The family plan was an individual health plan that offered at the time fairly comprehensive coverage at a high cost.  However, in defense of the plan, it was an HMO with fairly broad coverage.  This included outpatient mental health care.  Quickly, however, with the increase of premiums, the costs were almost too much to bear at almost $1000 per month for coverage, not including the $300 for the plan for the second daughter.  In addition, there were quite severe restrictions as to how many visits one could use for mental health (20) and very few days of inpatient (hospitalization) for mental health issues (10 days for every three year period).  In spite of those limits, when the time came to use the insurance, there was coverage. 

Then two nearly simultaneous events occurred.  The annual renewal of the policy was coming up  on July 1 and my older daughter turned 23 years old on August 1.

If you have ever purchased insurance and been advised that the policy in non-cancellable as long as you pay your premiums you have no idea what can happen to you.  True, you cannot be cancelled, but a company can refuse to continue issuing the policy with the same coverage.  In our case, that meant that the new policy that we were offered as continuation of our coverage was nothing at all like the old policy.  Gone was all coverage for any outpatient mental health treatments.  In effect, cancelling all coverage for that service.  Also removed were all benefits for routine physical examinations, and gone were the simple $20 office visit co-payments in favor of a $500 deductible followed by an 20% coinsurance charge up to a stop loss limit of expenses.  In defense of the Insurance company, there was a resulting decrease in premium, but the net effect was that we lost coverage for approximately $9,000 of benefits for a reduction of $4000 in premium, resulting in a net increase of nearly $5000 a year in expenses for my family.  The company was as cold-hearted as they could be, saying that is was just economics that drove the moves.  Of course, it was not intended to leave anyone without coverage because you were offered the lower cost program so you were not really cancelled.

The company did not care to reduce benefits, they simply eliminated them.  Their answer was that you saved so much premium and that most people would benefit.  I fail to see the benefit to those who put their faith in insurance only to have them desert you in time of need.  The fact that it was an individual policy made it even easier for the company to take arbitrary actions as there were no legal restrictions on their ability to remove coverage and do it with prejudice to people who had claims that would have otherwise been paid.

This was bad enough, but the really difficult problem was just beginning.  For those of you who have not navigated through the health insurance transition phase, there is nothing like trying to buy insurance for your child when they are no longer eligible to be covered on your family plan.  Worse yet, they now carry a diagnosis of a chronic disease and can no longer qualify for any type of standard insurance.  Even more devastating is the fact that their illness prevents them from working, thereby eliminating any possibility of joining a group plan.

That is where we thought we found a lifeline in the form of a state mandated program, the Oregon Medical Insurance Pool (OMIP).  It is supposed to provide coverage for people who were otherwise uninsurable.  However, in today's world we found out just how few people really are insurable.  Just the hint of a potential asthma condition, a mental health prescription or nearly any other issue other than a sore throat seems to make you unqualified to obtain regular insurance.  Luckily, or so we thought, our daughter was qualified to enter into the pool because she had existing coverage that she was losing.  Since she had been turned down for disability, she did not qualify for Medicare and or Medicaid, and was in the process of appealing that decision.  She was afforded coverage through the OMIP program and resumed seeing health care professionals.  By this time, we were now paying for three separate insurance policies with greatly reduced benefits even though no one had been without coverage and no premiums had ever been missed for payment.

Now the final catastrophe was about to happen and send me on a two year and four month trip into a bureaucratic version of hell.

If you have never connected with the process of placing your loved one on Social Security Disability, you should say a prayer and hope it never happens to you.  It is not what you want to go through.  It is good because it is there as a safety net but it is a hellish process that entraps those who enter the system.  The people who are in the system are compassionate and it ultimately does something like what it was intended to do, but it is torturous to go through.

When you apply for disability you are likely to be turned down.  In the case of my daughter it was not so much that she was not disabled, she clearly was, it was because I had tried to give her a start in life by giving her funds to put into a retirement savings account and she had accumulated too many assets to qualify for assistance.  We had to deplete her retirement accounts to spend them on her care and reapply for disability when those assets were gone.  This breaks your heart as a parent but you can understand the realities of social assistance.  What you have no control over is the timing of the date of disability that Social Security will pull out of thin air and choose as the date of the onset of the disability.  This is where you get into trouble with health insurance companies.  Health care coverage is invalidated when Medicare and Medicaid coverage is activated.  You have no control over the timing of when that date of eligibility will occur.  Indeed, you have a duty to inform the insurance company (OMIP) about the coverage afforded by Medicare.  In our case the problem got even worse.  We were notified that the coverage was afforded by Medicare and Medicaid more than 90 days after it was effective.

Apparently it did not matter to anyone at OMIP that it was impossible for us to notify them of the other insurance because we had no knowledge and could not have any knowledge of the coverage because we were not notified until after it took effect.  Worse yet, the Medicaid portion of the coverage will only go back in time 90 days from the date of their notification.  This was of no concern to either OMIP or Medicaid as they were not interested in covering anything.  OMIP accused us of trying to improperly obtain insurance when at the time we could not even understand the coverage process.  They then took the action of declaring a rescission of the OMIP coverage back to the day that the Medicare coverage took effect.  Medicaid then back dated coverage only to 90 days prior to their notification of coverage and that left a hole in coverage for multiple charges.  Worst of all, our daughter was in the hospital at the time this all happened.

If you are unfamiliar with the term rescission, it is a term that you never want to hear with respect to insurance.  It basically means that for practical purposes, it is like the insurance never existed.  Worse yet, in addition to not providing coverage, it also means that for no coverage you do not get your money back, they keep the premiums paid for the insurance and send you a bill for the amount they paid out in claims in excess of that premium.  To go one step further, they refused to cooperate and assist me in the process of getting payments from Medicare and Medicaid, who should have paid for the claims.

To add one final insult, the insurance company went back to the people that provided medical services and removed the payments to them that were made from the original date of coverage.  This is done by simple removal of funds directly from the account that the funds were deposited.  In this case, a year after the claims had been submitted and paid.

Then the fun of dealing with the system began.  First I protested the action and appealed.  That process was the worst process that I have ever been subjected to.  I was told that I could appeal but there was no way that I would win the appeal.  I was asked by one representative of OMIP if I was "going to shut up and quit whining and listen to how the system works." 

Three separate times I was sent bills of differing amounts that were allegedly owed to the Insurance company for claims paid out on invalid insurance, each with thinly veiled threats of collection action.  The providers that had the monies taken from their accounts also threatened collections action.

At the end of the appeals process I was asked point blank "What do you think we should do about the problem."  At least one of the women who heard the appeal presentation had tears in her eyes.

At no time did the insurance company ever offer to assist in getting Medicaid to pay their portion of the bills.  It was up to me to get the money.  When I did so, the insurance company demanded the refund be sent to them, not to me.

Over the next one and one half years many phone calls were made.  Visits to the pharmacy, phone calls and e-mails to people at companies were all pursued to no avail.  Finally, in a fit of rage venomous e-mails and phone calls to legislators and people at Medicaid started to move what appeared to be mountains.  I went so far as to contact the Governor's office.  The phone call I received left me with a desperate feeling as I was told, "You are under the mistaken impression that government programs coordinate with each other."

Finally, with the help of my state representative and senator, Medicaid began to talk to me.  At this point I was frustrated and bitter and lashed out at nearly everyone.  Even OMIP had their government liaison call me and discussed the problem.  OMIP finally recanted their position and sent a check for a refund of the premium and a statement that the account had no remaining balance.

It took 2 years and four months to resolve the issues.  What started as a health problem ended with a wimper and some brutal lessons learned.  My worst nightmare still lives on as I have been unable to get any legislator to take up the issue of coordination of health insurance benefits.  Since I no longer have an issue, legislators and Insurance companies want to close the door on the issue and it is too technical and detailed for the average person to understand.

The problem that still exists for any person who becomes ill enough to lose their job and become disabled and eventually end up on social security.  I have no faith that the system will treat them with respect and dignity.  It is more likely that benefit coordination issues will torture them or their loved ones.  I really wish it were not so, but it has given me a deep distrust of the motives of insurance companies and the wisdom of those who write our social benefit laws.  In a better world, no one should face what my family faced in trying to care for its members.  Unfortunately, when I asked one of the people at the appeal hearing if they just hated people with mental illness, she replied "No, this happens all the time to people who get really sick."

My question is how do people who work in that system day after day manage to sleep at night?


Please write me and let me know your thoughts and comments.

Webmaster Don

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Last modified: 05/15/08