Getting Beaten by Your Husband Is an Excuse to Deny Ins. Coverage?

by L.A.S.

This is unbelievable. I keep saying that I am not an apologist for the insurance companies. I try to portray them as reasonable, given the fact that they do have to make a profit to stay in business. And then they pull stuff like this.
A woman was dropped from her insurance plan because she was abused by her husband. Their rationale appears to be that because, she was beaten badly enough to need medical attention, she will probably wind up in the hospital again. Abusive husbands tend to repeat their behavior, in other words.
But to penalize the woman by denying her continued coverage is just unconscionable. That is penalizing the victim, and it is unacceptable.
You may read the whole article plus some commentary by clicking on this story: http://minnieapolis.newsvine.com/_news/2009/09/16/3279449-heartless-logic-getting-beaten-by-your-husband-is-an-excuse-to-deny-ins-coverage
A quote from the article: "Under the cold logic of the insurance industry, it makes perfect sense: If you are in a marriage with someone who has beaten you in the past, you're more likely to get beaten again than the average person and are therefore more expensive to insure."
ARRGGHH!! Sometimes I just have to scream, you know what I mean?
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Declined for Disability Insurance? Common reasons why, and what to do

by L.A.S.
The most common reasons for being declined for a disability insurance policy are:
1. Age
2. Dangerous occupation (often this includes building trades like electrician or roofer)
3. Employee of the U.S. Government
4. Income (too low or too high)
5. Lack of U.S. citizenship or green card.
6. New business or occupation (lack of actuarial data)
7. Overall poor health
8. Overweight, occasionally severely underweight people may be denied also)
9. Work or travel in foreign countries.
10. Works out of one's home.
In addition, the fact of having a dangerous hobby can cost you any kind of life or health insurance. A hobby of flying a plane is most often cited in insurance courses.

Common Diseases or Conditions that Cause Denial of Disability or Long-term Care Policies:
1. Asthma
2. Arthritis
3. Alcoholism or Drug Abuse
4. Carpal Tunnel Syndrome
5. Cancer
6. Crohn's Disease
7. Diabetes
8. Epilepsy
9. Heart Attack
10. Hypertension, especially if you take multiple medications
11. Lupus
12. Mental Disorders
13. Multiple Sclerosis (BTW, Minnesota has a statistically high incidence of M.S., and so dread disease policies exclude it in the list of conditions covered by the policy)
14. Overweight
15. Respiratory Diseases such as emphysema
16. Sleep Apnea

What kinds of strategies or limitations might you have to accept in order to get any type of disability insurance?
1. An exclusion for conditions related to the reason for the denial. Example: exclude injuries related to on-the-job accident/injury if the reason for denial was that you are in a dangerous occupation. This would still cover you for off-duty injuries or illnesses.
2. A longer elimination period (the wait between an injury or illness and the time you may first draw benefits).
3. A shorter benefit period. Perhaps you only have six years between now and planned retirement at age 65; you could structure a policy to stop when you turn 65.

4. A smaller benefit. To me, this is the least satisfactory option because almost all disability insurances pay you a maximum of 65 percent of your regular income anyway. (And that is based on your base pay, not your paycheck with all overtime and bonuses included.) You may as well just stash away as much cash as possible for a rainy day.
5. OR all of the above.

But just because you have accepted an exclusion for your occupation does not mean that you can never collect on an on-the-job injury. You may be able to prove that an accident causing a broken back, for example, would have incapacitated even a person with a healthy back. So the fact that you declared a back problem when buying the policy may not affect the legitimacy of your claim.

This is just a few things to think about when considering buying disability insurance or finding some other strategy for replacing lost income when you are laid up -- or laid off.

Wall Street Journal Has Story on Fighting Insurance Denials

Pushing Back When Insurers Deny Coverage for Treatment --
By Anna Wilde Mathews, The Wall Street Journal
http://www.marketwatch.com/News/Story/Story.aspx?guid=b6e08398424d449bb8ac46fc3c8a2565&siteid=nwtpf&sguid=LlOmLCZmMkSOlLZa0_8Pmw
Battling a health insurer when it refuses to cover certain treatments can be aggravating and time-consuming. But if you choose to join the growing number of people who are appealing coverage denials, there are several strategies that can bolster your case.

MORE ABOUT DENIALS

Sometimes getting a claim paid is like trying to get a promised mail-in rebate. That is, if you had to pay yourself for all the work you had to do to get it, you’d be in negative territory.
The most common reason for denial is: any guesses? It is an incomplete claim.

The insurance company needs what is called a “clean claim.” A clean claim has all the required information on it, your identifying information (like name, address, date of birth, policy number), provider identification (dr. name, address, etc.), the date of service, and information about the service itself (office visit, code, diagnosis code or description). That sounds like a lot, doesn’t it? Not really. All that fits on a standard one-page form called a HCFA (for doctor, clinic, and medical equipment claims), or on a UB-92 (for hospital claims).

Do not give up automatically upon receipt of a denial letter. Often a claim will be resolved without your doing a thing, because a duplicate letter has gone to the provider. The deficiency letter is more likely than not, perfectly intelligible to the billing department, and the followup claim with the requested material is quickly sent by return mail or fax to the insurer. However, the handling of the reply is not handled with the same urgency as the initial claim. If the insurer requests medical records, x-rays, a pathologist report, etc., the process will stretch over a month.

So before launching a full-scale attack on the insurer, please call the provider’s billing department and check if they have received the same letter and what their response will be. If they are already handling it, or if they treat it as a routine matter, you can resume your normal life. If on the other hand they do not deal with insurers, or do not waste energy on appeals, etc., then you will have to go into high gear.

Typically ninety percent of consumers drop their appeals before exhausting their options. According to a study by the Kaiser Family Foundation, 52% of patients won their first appeal for each claim made. If your first appeal gets turned down, make a second appeal because second appeals won 44% of the time. And third appeals won in 45% of cases. There is no reason to give up if you truly believe that your policy covers a given procedure. Follow the instructions for an appeal. An informal appeal is fine for routine services.

First, pull out your denial form or letter and look up what the denial code is and what it denotes. Then pull out your copy of the policy and go through its provisions with a fine toothed comb. It is true that some of the finer points are not given in the copy that you own, such as definitions of terms, or which doctors are in the network, etc. But the insurance laws are such that the policy you have been given, with the application and any riders, constitutes the whole contract between the insurer and you -- (see section on Your Rights As An Insurance Consumer) -- and they cannot add new material wholesale after the fact of granting you coverage. (Language in the contract will refer to providers in the network, and even though the providers are not listed in the contract, this is a valid part of the contract by virtue of being referred to in the section on how payments are calculated.)

So now you have read through your policy and you still feel that your procedure should be covered. Gather together your denial, explanation of benefits, your appt. calendar, any notes you kept on doctor visits and doctor recommendations. This is especially true for emergency visits to the E.R., when they will want to know if you called your doctor’s office and did he/she send you to the emergency room.

Call the insurance company’s customer service line, or go to their website, and make an inquiry as to the exact reason for the denial or why payment is delayed. It may be that the definition of a term is not the same as in ordinary English usage; many definitions are specific to insurance. You should be able to check this information on the insurer’s website, or look up material on the FAQ page of the website. Try asking the customer service rep what the reason is for the denial, and do so politely. The rep may not have that information available yet, as your claim may be stuck in processing. Get a name of a department supervisor and his/her phone number to call next. Then call that person to ask him/her to check into your problem and ask for a followup letter.
The next step is to go online to the NAIC website. This is the National Association of Insurance Commissioners. On the website you can click on a button to contact your state commission. Then you will be able to access a great deal of information about health insurance in general, and about how to proceed in your case. (Your state office will often have email or instant response to your complaint.) Your HMO may also have an appeal task force; ask about the correct procedure to appeal your denial.

Make note of any deadlines for receiving an appeal. If one is given and you are mailing a reply within a week of that deadline, send it certified mail to prove that you met the deadline. Never send originals of insurer paperwork (but keep copies for your file).