View Single Post
  #28  
Old 05-26-2009, 10:46 AM
Harrison's Avatar
Harrison Harrison is offline
Administrator
 
Join Date: Oct 2004
Posts: 7,010
Default

LAURIE'S NEW BOOK IS HERE!
Hot off the presses!
It's a CD!

"The Sample Appeal: More Insurance Warrior Wisdom"

Check it out:
www.theinsurancewarrior.com/thebookandthecd.html

****************************************

All Plan Language is Misleading

I recently had a call from a newspaper reporter, asking for information for an article about "misleading plan language."

The reporter was not looking for my opinion. She assumed that I offer a service sorting out people's medical bills -- a type of patient advocate, or a reimbursement specialist. She wanted me to provide the names of several patients who had gotten into trouble because of "misleading plan language." Her request made me reflect on both what I do, and on what role misleading plan language plays in the larger world of health insurance.

First, let me say that I do not offer a service. I speak, I teach, I write on insurance topics. I fight the occasional appeal, but only if it is difficult, compelling, and lifesaving.

Medical bills give me a big headache; I want no part of them. That is why I write powerful appeals up front -- so that there will BE no medical bills.

The reporter's question was based on the assumption that a benefits booklet is a good faith effort by the insurer to explain your coverage, and the only problem is that a few phrases might be misleading.

People, please. I am asking for a paradigm shift. The entire purpose of a benefits booklet is to mislead, and all plan language is misleading.

What is a benefits booklet?

My plan documents?
A summary of my coverage?
An explanation of what my insurer will pay?

Think again. The benefits booklet explains the medical services covered by your insurance plan. It just doesn't include all of the circumstances under which they will NOT cover them.

In my opinion, that is misleading.

What is the purpose of a benefits booklet?

To make you feel well-covered and financially secure, while shifting more and more of the medical expenses to you.

It's a tricky business, one which requires very misleading language.

Last year, a friend asked me to review three different insurance plans. She needed to decide between them, and she figured that the Insurance Warrior could shed some light on the situation.

It has been twenty years since I chose a health insurer, or studied a plan summary. Twenty years ago, benefits booklets were pretty straightforward. As I examined these three insurance plans, I was amazed to see how complex, opaque, and generally misleading such insurance documents are nowadays.

Dig a little more deeply into any plan documents, and you will see all of the ways of not paying that are built into the plan language. Powerful denial words are mixed in with harmless coverage words.

I know a lot about how insurers use words to deny treatments. I was amazed at how insurers are now using the same words up front -- to lay the groundwork for not paying later.

They give with one hand, and take with the other.

How does the language mislead?

The biggest-ticket item in anyone's insurance plan is prescription drugs. Let's look at the Plan Summary of Acme Insurance, and see how the language misleads you into thinking that you have coverage, when you don't.

The misleading language starts with the name of the plan: Acme Insurance Comprehensive Plan. Sounds like it covers just about everything, doesn't it?

The Comprehensive Plan is the most expensive. One of the extra benefits that you are paying for is prescription drug coverage. And yet, when you put all of the language together, you are not covered at all. What could be more misleading?

Let's count the ways in which Acme shifts the prescription drug costs to you:
  • You have a yearly maximum of $2,000 -- just for prescription drugs. Those of you who have had cancer know that you will use that up in a week. Avastin, a cancer drug, costs about $13,000 per month. Erbitux, a monoclonal antibody also given for cancer, costs in the neighborhood of $62,000 per month. You are exposed, you have no coverage.
  • In order for Acme Insurance to pay for it, a drug must be on the "formulary." Guess which drugs are not on the formulary? The most expensive ones, and the most commonly prescribed ones.

    How can you know ahead of time what illness you may get, and whether the drug that treats it will happen to be on the formulary? The formulary shifts the largest burden of drug costs to you, while giving the illusion of coverage.
  • In the fine print, Acme states that they have a "closed formulary." Do you know what that means? On the Acme website, it says, "The closed formulary provides value." Talk about your double-speak. In a closed formulary, the insurer only pays for the most inexpensive, generic form of any drug. Value indeed -- to the insurer, not to you.
  • The drug must be on the formulary, you only get a pitiful $2,000 per year. Guess what else? Acme only pays 50% for any and all prescription medications that they do cover.
  • But it gets worse. There are three "tiers" of drugs. For the more expensive drugs that Acme has generously included on their formulary, they don't pay even 50%. For these "first tier" drugs, they pay only 30%.
  • Oh, and one more thing. Acme can deny any and all prescription drugs that you might need, whether or not they are on the formulary. All they have to do is call them "not medically necessary." Not medically necessary according to whom? According to the Medical Director of the insurance company.
Sometimes I wonder why they bother. Why don't they just say, "We don't cover prescription drugs"? Because people want prescription drug coverage. Or at least something that looks like coverage.

Know that all plan language is misleading. But also know that all of the forty-four appeals that I have won have been for totally out of benefit, not covered, out of plan services. And yet have always paid, if I lean on them in just the right way.

When it comes to health insurance, everything is negotiable. But only if you see through misleading plan language, and turn it to your advantage in your appeal.

Happy and peaceful Insurance Warrior-ing,

Laurie Todd
__________________
"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Donate www.arthropatient.org/about/donate