insurance question

[CindyLou]

Hi everyone, While I am nervously awaiting my second appeal, I have a question: our healthcare provider is thru my husband's employer, and it is a privately held/owned co. My husband is a senior VP, been with co. over 15 years. His boss (owner) hearing about my surgery, graciously gave Rick his earned bonus early (normally if you qualify, you receive in Sept). Now my husband is too embarrassed to ask him to just authorize approving my surgery. I'm saying, return bonus until Sept.(which still won't cover surgery), and ask him politely to just authorize the surgery. Is this way out of line? He could just authorize it couldn't he? I don't think we can hire a lawyer under these circumstances, against the insurance. Wouldn't that be almost like suing the company, or no? Please advise. I'm confused. Thank-you. (ps: in Germany, do you pay separately for your artificial discs?)

[Terry]

CindyLou:

Your denials imply to me that, even though your husband's company is private, they are not self insured. This means they pay premiums and you are still at the mercy of the insurance company. This would mean that you husband could request the owner to argue to the insurance company on his behalf but they could still deny it.

I am the executive of our corporation and could not control the outcome of the insurance company. They did ultimately pay after two denials. They paid the full amount as I had already met my deductibles for the year.

I went to another clinic in Germany and wired the whole amount pre-surgery as requested. The insurance company then sent the hospital a check and they wire transferred the full amount to my bank. Boy was that ever exciting. I like unexpected money especially in that amount.

Good Luck CindyLou.

Terry Newton

[CindyLou]

Terry, thank-you for input. I think I need to find out for sure if we are self-insured. Great news for you that they paid! I just assumed private co. = self-insured. I'll find out.

[CindyLou]

OK, so I just found out the company is self-insured. So, basically, in my estimation this means, the head guy (whose office is right next door to my husbands!) could just call the insurance and tell them to approve it, right? Any suggestions from anyone on how my husband could approach this, especially since he was already given his bonus early to help? Are we just coming off as greedy? I will add that the owner (he inherited co from his Dad, who was a very generous, thoughtful man) is in his 50's, has never been married, no kids, no appreciation or real understanding of family life, and how important my health is to my husband and his career. During an appeal, does my appeal plea go to the owner of the company, since it's self-insured, or possibly our HR division during the appeal process??? Any advice on how my husband could approach this would be greatly appreciated. Thanks again Terry for your input.

[LBP]

Cindy,

There was a guy ESL in San Diego that discussed how he successfully got his company (self insured) to pay for his surgery. His post was on April 6, 2005. I cut and pasted one of his posts below:

earlier post from ESL:
successfully appealed to the benefits committee at my work (my employer's health plan is a self-retained plan like yours)......here are some things that helped:

1. i have been employed here 15 years and the company feels its a high likelihood that i will be here for at least another 5 years (ie, my future healthcare costs will be theres).

2. I showed them how a fusion (the alternative) would cost just as much in the short term (if not a little more), but by the time you add the additional follow on costs (ie, more drugs and care) plus the way more loss of time from work, ADR is actually cheaper than fusion!

3. I showed them some study data and european data demonstrating ADR's level of success.

Granted in one meeting!


Cindy,
I think there was some other discussion about invoving the person assigned to your case from the 3rd party administrator who takes care of the processing of your companies health insurance.

Good luck

[CindyLou]

LBP,

Thank-you for that lead. I'm not sure how my husband wants to address it with his employer. I figure, all he can do is say no, I'm not going to open the door and cover this adr for your spouse, because there will be others behind her who will want it then. He may not be thinking that at all. I don't know. Just wait and see mode. In any event, thanks for your input. I really appreciate it.

[Terry]

CindyLou:

You bring up good points about the bonus but consider this:

1. Why should you spend a bonus on a surgery when that is why you have insurance in the 1st place.

2. A bonus is an earned benefit from the company; i.e., An atta-boy/girl for the company performing well and meeting up with a revenue projection or sales amount. The companies success is dependent on good employees and the bonus is a reward.

3. 15 years is a long time to be with the company and being in a senior management position means his position is solid. It would take a considerable amount of resources to lose him and train someone else for the position.

4. The boss should be concerned for his employees welfare and happiness as this is beneficial for the entire organization. On that note it is in his best interest to take care of the spouse as that is essential for his overall well being and the company's well being.

5. You need the surgery and did not ask for this accident to happen to you nor the related consequences. The company should be equally concerned about your health and welfare as well as the employee. Your husband's company's structure implies that self insured still covers family members.

6. LBP laid out the structure of your argument to a tee and it sounds very plausible and doable.

7. Neither of you should feel ashamed to stick up for a benefit that is part of the company's benefit package and, that is earned.

You deserve to get well and to have it covered!

Go with God

Terry Newton

[CindyLou]

Terry, all very good points and I copied and pasted it to send to my husband. I don't think he took any action today tho, or he would have called me. And then tomorrow he leaves on business to Boston, so another week shot. I just wish he would engage his boss in a non-confrontational way to present my case/appeal. I know it's not easy, and I don't want to make him feel pressured...do it on his timetable, at the right moment, but the clock is ticking. Thank-you for all the good advice!