Screwed by AARP Healthcare

[Ann F]

Just so you all know, I've been denied by the new AARP health care insurance for being honest and telling them in my application that I was due for ADR surgery on back, as in the free trials for Activ-L. I disclosed all, in my signature. I'm between jobs, trying to avoid COBRA which will cost me $600 a month, but until I find a job, I get to pay that. Nice system we have here.

[spotty14]

That's the pits for sure. What was the basis for the denial? Pre existing condition? Have you checked to see how to appeal their denial?

[Mariaa]

Ann,
I just let go of my AARP supplement and am using my husband's Blue Cross Blue Shield policy for medical however, since my back injury was a work related injury and WC case intiated in 1982 and settled with lifetime future medical on my low back, when I was intially obtained MediCare benefits, I had to sign a form waiving care on my low back because of WC coverage.

The other thing with AARP is I believe that anything that isn't approved by Medicare, they will not cover either and ADR isn't covered by Medicare as far as I know. I may be incorrect there~

6 months after an appt. I had (last summer) I recently received charges for something Medicare doesn't cover, therefore AARP wouldn't pay. Even tho one is to sign a form when having labwork done that addresses responsibility to pay, I was surprised to receive it so much later...

I recall back when I applied for AARP I also informed them of plans to have ADR surgery, however said it would be under WC and I had already signed a waiver form in terms of coverage thru Medicare. I suppose that's why there was no hesitation to accept me..

I hope I won't have trouble becoming insured with them again as AARP while it can be costly if adding on dental,vsion and pharmacy, still is likely cheaper than COBRA which I did for the longest period I could retain it.

Really sorry to hear you were denied... I guess it's because of their position on ADR coverage, tho doesn't make sense if they aren't going to have to pay except in terms of perhaps follow up for low back or any related back pain...

[Dale S]

Our systems stinks. Prior to the early 90's, insurance was much less restrictive. Enter HMO's who saw a way to make money by limiting our access to doctors, and doctors access to treatments they deemed necessary. I don't know why our government doesn't interfere, restricting HMO's ability to dictate health care. Could it be our entire system is slightly, if not completely, corrupt?

[LMay4111]

for general Information any part of the body that you injure at work is not covered ever by medicare medicaid or any other private Insurance this is federal law : You also should be aware that you do not have to have filed a claim for a work injury for it to NOT BE COVeRED if you sought medical treatment and it is in the dr's notes that you were injured at work that is all that is nec for a claim to be denied at the time of medicare ect thus the reason you recieve lump sum monies from a wc carrier when you were hurt for work one other thing you must be aware Lifetime medical is a myth because you must prove to the comp carrier unless it is real obvious and recent they will deny your claim for benifits and treatments and require you to file and literally litigate your case again the problem with this is that most attys reuire a cash retainer of between $5000.00 plus before they will go to court because they are fighting for benifits rather then cash settlments and trying to enforce a promise which the wc carrier had no intention of doing ie future medical is in fact just an illusion it does not happen because the person must prove the problem they want repaired is related to the wc injury and not some other factor in their lives ; I deal with many of these issues in my practice and tell clients that what they get at settlement is basically all that they will get and that future medical is just a myth and they should treat it that way and ensure that when they settle they save out enough to pay for any future medical care they need because that part of the body no longer has any medical coverage from any souce except the cash they got at settlement
LInda ie LMay4111@aol.com

[Mariaa]

[QUOTE]Originally posted by Mariaa:
My WC claim was in 1982. I was awarded what was called "Lifetime" Future Medical Benefits but I've been told several times from Claims Adjustors it is just Future Medical.

Anyway, until recent CA.reform with WC, these benefits served me quite well. Pretty much what was ordered was authorized. Now it's nothing like that. Everything goes through Utilization Review (like an HMO).

After all these years with Future Medical I'm pretty much being advised that a beneficial idea to me would be to settle my claim.

I know that the insurance company of course has a vested interest in this happening...

What I wanted to get to bring this back to is that in 2003 when I became eligible for Medicare benefits, I had to sign a waiver or release form stating the injury to my low back was being covered by WC and Medicare wouldn't cover this part of my spine.

So this much I'm aware of... right now the Claims Adjustor is talking about the option of settling the claim and Medicare set aside benefits. From what I can decipher, the amount I'm going to be offered isn't enough to last my entire lifetime with the current pain situation I have, but would probably cover a future surgery ?? but I have to have a plan from a surgeon (have had 3 surgeons propose surgery but none written the right way for whatever is going on in WC's mind..) of what is proposed and Pain Management care afterward...

Really given the fact the surgery could be a success, partial success orpartial or complete failure means there's much room for variation there..of course not to WC. Often one spine surgery begets another ...While I can't see having to fight for every epidural I need to have 3x/year (that is a conservative amount), I have to wonder if this settling out is the way to go or not... I imagine lowball figure is what would fly with a WC settlement~

When one settles out Future Medical, I think it would be advisable to retain an attorney but the Claims Adjustor said that I will get the same amount one way or another, and that hiring the attorney will cut off around 15% of the award... still seems worth it if it's going to make sure everything is done correctly and to best benefit me...

[tmont]

Originally posted by Dale S:
Our systems stinks. Could it be our entire system is slightly, if not completely, corrupt?

Following this thread and others, hearing how hard it is for people to get the treatments they need, is a real frustration to me as an American living abroad. The USA is supposedly the richest and most well-equipped nation on earth, yet its citizens most definitely do not fully benefit from this advantage unless they can pay out of their pockets. Is it corrupt? Oh yeah.

But is it really better in the long run elsewhere? I used to think so, but now things are changing here too. France has socialized medicine,meaning 26% of our salaries is directly taken off the top for SS and basic health care. Most people also pay a supplementary insurance company to cover the percentage of what 'basic health' will not (to be fair, 'basic health' is pretty extensive; I was wary at first but have always received great care).

In the beginning I choked over this. When you're you're young, not sick, with no kids, this is a lot of cash and it looks like it flies out the window. For years it did.

But as soon as there's a problem, or you get pregnant (prenatal care and delivery) and have kids, you see the advantages: you rarely see a bill, or it is in penny change. I pay zero for most doctor's visits (including specialists) and medications, hospitalizations, surgical interventions and tests, and they have been extensive these past few years with my spine probs. 'Luxury meds' and 'luxury surgery' were pretty much all that were 100% out of the patient's pocket. Even middle-of-the-night house calls were reimbursed!

Unfortunately, with such a system there has been so much doctor-patient abuse that the well is drying up and changes have to be made. People think that because they pay so much into the system, they're entitled to milk it for all it's worth when they're sick: doctors write far too many prescriptions (I've come out of the pharmacy with a grocery bag full of largely superfluous meds), precribe paid work leaves for basically nothing, and order complicated and expensive tests on a whim.

I've also seen people throw fits in the pharmacy because it was suggested they accept the generic rather than name brand drug (btw, you won't see any ads on TV or in magazines for meds here; their prices are fixed by the gov't), or because toothbrushes are not reimbursed! Makes me want to smack some people upside the head...I've refused a med to hear the pharmasist say 'why don't you just take it? It won't cost you anything/you've already paid for it' (??!!)

Small wonder things have to change. So now, we can no longer see a specialist without a doctor's referral, many brand-name meds are no longer reimbursed (generics are), and the waiting list to have some tests like MRIs and CT-scans is getting longer and longer.

Excuse my rambling, but I've often compared the health care systems between the two countries and wondered if the solution lies somewhere in between the cruelly tightwad attitude of the US and the have-it-all mentality here.

Problem is, while the insurance companies are the 'abusers' (IMHO) back home, it would appear that the citizens themselves are the greedy ones here. If we had such a system back home, would the abuse and corruption then shift to the patients' side?

Probably...after years of having to fight for the basics, much of human nature would want the best.

Don't have the solution, but the health care issue is both extreme, and absurd in both protocol and proportion.

[Justin]

Ann--I am sorry to hear you were denied. This is unacceptable.

Trace--Your post is well needed and the topic of universal healthcare here in the States has recently been thrown around. I don't think the post below is a solution by any means, but it is getting the US to think along different lines:

Required insurance law sets standard

Poll: 55 percent would support law like that in Massachusetts

BOSTON, Massachusetts (AP) -- By next summer, Massachusetts may cross a threshold that has eluded presidents, governors and other political leaders for generations by becoming the first state to require universal health care coverage.

Massachusetts took a major step toward that accomplishment Wednesday when Gov. Mitt Romney signed legislation designed to guarantee coverage for virtually all residents by July 2007, including an estimated 550,000 people who are now uninsured.

The law has set a standard for other states and thrust Massachusetts to the forefront of the national debate about how to dramatically expand health care coverage without creating a single government-controlled system.

Even as he signed the law amid fanfare at historic Faneuil Hall, Romney faced criticism for vetoing a key portion of the legislation: a $295 per employee annual fee on businesses that do not provide their employees with coverage.

The law also provides subsidies and sliding-scale premiums to get poor and low-income residents into health plans and require those deemed able to afford insurance to purchase a policy.

"We have found a way, collectively, to get all of our citizens insurance without some new government-mandated takeover or a huge new tax program," Romney said.

Romney is weighing a potential run for the Republican presidential nomination in 2008 and the law could be a centerpiece of that campaign.

Speakers at the ticket-only signing event, attended by more than 300 people, included Democratic U.S. Sen. Edward Kennedy.

"After so many years of false starts, our actions have finally matched our words and we have lived up to our ideals," Kennedy said. "You have given Massachusetts just what the doctor ordered."

An ABC News-Washington Post poll of more than 1,000 adults nationwide released Wednesday found 55 percent of Americans would support a health care law similar to the Massachusetts model in their own states. Forty-one percent opposed. The poll had a margin of error of plus or minus 3 percentage points.

Romney used his line-item veto power to strike eight portions of the bill, including the $295 fee. He said the fee was not needed to pay for the reform.

Leaders of the heavily Democratic House and Senate have said they would override the vetoes. House Speaker Salvatore DiMasi called the vetoes disingenuous, saying the law was crafted with concessions and compromise.

"To change anything will disturb the delicate balance that made this law possible," DiMasi said.

Business and hospital leaders also criticized the veto of the fee. Massachusetts Hospital Association President Ron Hollander said it threatened the balance of the bill.

"I think it is important that all the parts and all the parties stay together," he said. "The employer assessment is critical."

Romney, speaking to reporters after the event, defended the action.

"There are many businesses who have been flooding my office with calls as well as business associations, that are very concerned about it," he said.

Under the law, those who can afford insurance but still refuse to get it will face escalating tax penalties.

The cost of the health care package was put at $316 million in the first year, rising to more than a $1 billion in the third year, with much of that money coming from federal reimbursements and existing state spending, officials said.

Copyright 2006 The Associated Press. All rights reserved.
http://www.cnn.com/2006/HEALTH/04/13....ap/index.html

[freshfig]

Maria,

Is there a statute of limitations set for you to file a claim regarding your WC? I would check that out as I think there is a two year statute of limitations.

Best wishes for getting this all sorted out and starting on the road to recovery!

[Mariaa]

Trace,
In a sense there is a healthcare system in place for the indigent that qualify, and it's called Medicaid and MediCal here in California, and I'm not sure what all else in other states.

Working as an RN and Nurse Practitioner in mostly indigent care settings, I have seen what you mentioned first hand, the balking and even rage with regard to having to pay for anything...like a diaper even..

Yet here tax paying people with benefit plans from employers can often choose between an HMO plan which is very tightly managed by "gatekeepers" who are usually not medical personnel but rather lay people with no knowlege of medicine given jobs and put in control of decisions as to care people can receive.

And PPOs and POS.. plans that differ in the amount of deductibles, copays and the like tho offer more freedom of where people can go in and out of network with so much out of pocket cost.

I believe AnnaPurna has mentioned a plan also which I am not familiar with but if you look thru her posts you'll find mention of it.

There's Medicare for the elderly and disabled however, there's much more cost involved in supplemental plans to cover what Medicare doesn't cover, dental, vision, and drug plans that add up to a fair amount and then are restrictive in cost..

There are also HMO plans that seniors/disabled can opt for and not pay for care or not pay nearly as much as with other plans mentioned.

California has some other plans for qualifying population and I cannot list them all as I'm not familiar with them all, suffice to say I've worked with patients that had every kind of plan and also been on committees/wrote policies/procedures regarding various plans (technical writer).

It's a mixed bag here in the states tho it seems that many think that everything should be free...

As far as my WC injury and claim goes, it goes back to an industrial accident in 1982 involving my back. And yes, I have felt entitled to utilize these benefits as other insurance plans wouldn't cover this injured area once it's known that I have WC insurance covering the area.

I hope you weren't implying that I am greedy for wanting to continue to utilize benefit assigned me... I don't think that you were implying this although if you are, I wouldn't be happy with that implication.