Re: insurance

[Guest guest]

Marilyn

Thanks for your enlightening letter, I'm off to re-read my homeowner's insurance

now to double check my info before Mr. Adjuster gets here... Yikes!

Mom to Kennedy 23 mos old CHARGEr, 10, 8, and wife to Graeme

New Brunswick, Canada

Visit the " Weir homepage " at: http://www.geocities.com/SunsetStrip/Palms/5716

ICQ #1426476

Re: insurance

Unfortunately, often Rick knows more about the coverage under insurance than

the " customer service reps. " , adjusters, or anyone else - including the

benefits coordinators at work! Since his employer is self-insured, and

administered by an agency (alright, it is quite large, admittedly) the

agency isn't aware of " extra " things the employer is opting to cover.

Example: Rick had to dig and found out that we DID indeed have at-home

service provided for within the guidleines of our policy. However, if you

just called the insurance administrator, they said no we did not. It was

because they looked up a specific type of insurance for self-insured

companies, but didn't look up about his particular company. We were being

kicked out of the hospital (so wouldn't " catch " anything else from

the hospital following her trach placement - she was there 10 days) and had

no time to make arrangements at work, home or otherwise! We were going to

try to find private nurses, then found out we were covered under insurance.

If you have private insurance, go over it and over it and over it until you

know exactly what you can or cannot get. Knowing our coverage has saved us

many times from not getting something paid, or knowing how to get our

doctors to get across the point in the insurance admin.'s language that has

reversed a denial. It has also meant we haven't inadvertantly switched

insurance types without adequate coverage for . (Found out we'd get

lower premiums for one type, but growth hormone replacement therapy is

specifically excluded. The amount of the growth hormone far surpasses any

annual savings we'd have had from lower premiums.)

Also, as frightening as this may seem, the case managers, who sometimes

decide your coverage for nursing hours and equipment, do not always have the

practical application knowledge that would be best in making determination

of benefits. As an example - and some of you know this story -:

was trached, on CPAP with supplemented oxygen, and restricted to

home except for doctor appointments, of which it was arranged she would be

the first appointment of the day so we could get her in and out quickly.

(Needless to say, she was very fragile!) The case manager called me at work

one Thursday and told me that starting the next week (Sunday was the actual

work schedule for the nurses) we would not have ANY nursing! We were going

from a 12-hour per day, 5 days a week, down to none! When I asked why, she

stated that was, at 18-months old, " probably old enough and stable

enough " that she didn't need them. I asked if she knew that was

restricted to home, on a trach, CPAP and oxygen, and was suctioned as much

as 18 times an hour. She said she had reviewed the nursing notes and found

that was " stable " . I replied that was stable because we had

nurses! DUH!!! Her reply was to ask that, " You take her grocery shopping,

don't you? Sounds stable to me. " I asked what/who's report she was reading

because can't even go to the doctor unless it's the first

appointment. We reviewed a little more, and discovered she knew nothing

about what was really in the reports from the nursing service, and she had

no experience with trached patients of any kind, let alone an infant! Then

I learned she had gone straight from nursing school to the insurance field!

If I hadn't been so relieved that the nursing hours weren't cut, I'd have

filed a formal complaint with the insurance regulatory committee. Problem

is, that is State only, and they don't have jurisdiction beyond state lines.

Our administrator is in another state from where we live. Darn!

Anyway, I always love venting about that one! Like they say about property

and what counts (Location! Location! Location!); I say about insurance -

Know your Coverage! Know your coverage! Know your coverage! If you need an

insurance lawyer/attorney/whatever to figure it out, ask them. Don't count

on a Case Manager (who works for the insurance company, by the way!), or a

Benefits Co-ordinator knowing the ins and outs. Rick has been told time and

time again, " but and your family situation are the exception. " Our

reply is that that is why you have insurance! And that is why we point out

the flaws in the system: So it is not such a struggle for others who

follow. We are not the first family to have a child like this, and we won't

be the last.

Sorry so long - back to the old style Marilyn!

Friends in CHARGE,

Marilyn

Ken (10), (7, CHARGE) and Rick (Mr. Insurance)

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