Anyone around tonight? (Wednesday) - My insurance company

[Metamorph]

I am done. I am completely done being screwed around by my health insurance. I am submitting an online complaint to the state insurance commissioner. I might also see if can get some legal help through the gender center. 

For my top surgery which I have written pre-approval from my insurance for the full member rate, they are basically paying for 1 boob and no anesthesia. It's so fucking ridiculous. They have given me so much shit over this and my mental health benefits for years and I am not taking it. 

Anyway, I am verrrrry tired and if someone is around and can read something and tell me if it makes sense, that would be great. 

[Laura J]

I can help.
I'm not an expert in legal lingo, but I will try.
You can email to [e-mail]

[Metamorph]

Awww, we just submitted the stuff but we may be asking for help again.

we will give the short version of what's going on. we lucky (well, theoretically) in that our insurance covers top surgery.

we had to get pre-authorized. we did everything right but first time they only approved an office visit. no procedures. we called up and they said they never received the correct codes and we would have to resubmit. no appealing or amending. we resubmit. check on status and they are processing our "office visit" request. this time we on to them. spend 45 minutes on the phone arguing. first they say they don't have the codes. then they have the codes but it's too late and we have to resubmit. then it's the doctor has to call and tell them the correct codes. 3 times we asked to speak to someone else, twice mentioning a supervisor and she wouldn't pass me on. then when I said I had no choice but to go to the insurance commissioner she enters all the codes and two days later i have my pre-approval

so had the insurance and submitted the claim and.... For both nipple reconstruction they are paying at 25% because " This is because more than one procedure was performed on the same date of service." For the mastectomy they paid one at the full member rate and paid the other at 50% because "We paid 50% of the reasonable rate for this procedure, because it is not the primary service" and they did not pay the anesthesia at all because "The charge for this service is not payable because it is considered part of another procedure performed on the same date"

[Deleted]

Hi, Metamorph! I don't know if you'll appreciate this intervention on my part, but after all you did post this on the "Rant" forum, so maybe it's OK for me to go on a bit of a rant here.

Just yesterday I was chatting with a couple of my friends on the topic of health insurance. It's relevant to point out that we're Irish/European and so we're not at all unfavourable to the idea of "socialized medicine", something that a lot of Americans have a horror of.

For me, socialized medicine makes perfect sense. The problem with private health insurance and private health care is that health insurance companies and health care providers need to make a profit. In the case of insurance companies (we'll leave the health care providers out of it) the result of this is that they have every incentive not to pay out on a claim. Every claim they pay reduces their profits. That is, the way I see it, they're not really in the business to help people get better. They're in the business to make money.

Therefore, e.g., if you might have some genetic predisposition to a certain condition, then you may well have to declare that upfront. And what will that do to your chances of getting insurance or getting paid on a claim later on? The result can be that those who are in most need of insurance might not get it. Health insurance companies love people who don't really need insurance because they're naturally healthy.

This is why in my view socialized medicine makes perfect sense. Everybody who lives in a given country pools their money, and those who most need help should get it. There's no need for the national health service to make a profit. As long as it's staying afloat, that's all that's needed.

Now I think the main objection to such a system is, Why should I pay for somebody else's health care? For one thing, you never know when you or one of your loved ones will need it. And then somebody else will be helping to pay for you. And secondly, all of us pay taxes towards things we don't really approve of. It's simply one of the compromises we have to accept if we're going to live in modern, organized societies. So we need to decide whether we prefer to live in modern, organized societies.

But one big consequence of socialized medicine would be that transgender people would get the health care we need. It wouldn't be left to some private guy who's trying to make a buck to decide what care we're going to get and what we're not. A sensible society will recognize that transpeople have very real needs, and those needs will be seen to like any other. And if it turns out that I'm paying for somebody else's surgery, let me know. I'll bring you flowers at the hospital.

[Deleted]

Having formerly been a claims adjuster I can attest to the fact that a letter to the State Insurance Commissioner may change the situation. Outline the fact that you were initially led to believe by your insurer that the procedures were covered and now that you are in recovery you find that the insurer has taken the liberty to parse what they will pay after the fact and that they were remiss in their failure to divulge that up front which constitutes a breach of good faith. Use these same words and I believe that you will get favorable results! Sometimes insurers lose sight of the fact that your insurance policy is a legal and binding contract between both parties and that if they fail or fall short of their end of the commitment that the Insurance Commissioner has the authority to end all of their business in this state, so you have a lot of clout at your disposal.

[Ativan Prescribed]

One of the things that 'socialized' (not to be read as if it is some plot to take over the country and take your guns away and all that really incredibly stupid assed shit that right-wingnuts come up with, because none of that is really happening and no the states that accept equal rights for all have not turned into the gates of hell, surprise , surprise...) healthcare is so basic, that most every country that isn't run by a dictator (and even then some still have it) because it makes healthcare a national priority, rather than something that insurance companies pay out profits to those who already have more money than they know what to do with, those people who collect money, it is an actual disorder and they won't have to spend a lot of money out of pocket to be cured of this totally mental condition that isn't that far away from those who collect more ammo and guns than the Apocalypse that isn't coming, than they could possibly use before being over run by thousands of people who know they have a lot of guns and probably also have way more food and other shit they won't need anyways.

They will have this disorder either fixed or at the very least have decent real counseling and/or therapy to help them through life without being assholes, which isn't the name of the disorder, but one of it's symptoms, not that all assholes have this disorder, but they to will get the same kind of therapy they need as well, without having to pay out of pocket for it, they will get what they really want, and that's for someone else to pay for it, just like everyone will, because hey, it's kinda like equal rights and all that shit, sorta like being a decent human being, which is what those disorders prevent most of those people from actually being, and they wonder why most everyone dislikes them, it's only a disorder, but one that is easily fixed and is preventable by having healthcare taken care of by everyone pulling together and sharing what they need to assure that those who don't have those big bucks won't be filing for bankruptcy which costs everyone even more money in the end.

So something as simply being a decent human being and allowing themselves to think of healthcare as universal and in the long run will still make the rich assholes rich, who can have that disorder taken care of, using someone elses money?

How much fucking simpler can that be?
Isn't that what the rich control freaks want in the first place?

Or is it that they also have the asshole disorder that has basically the same therapeutic resolution and care that would also be available with other peoples money, which is what they wanted as the assholes they are?

It's a win-win kind of deal, and no, Cuba and the communists are not behind this, it is only the overly rich bastards that can't think past their hand sticking out and not begging for money, but demanding it or they will simply spend even more of it to make their point, because they still suffer from, lets just call it assholeness, so they can understand in plain talk what it is that's keeping people from getting the healthcare they not only need, but deserve as a right to be able to pursue life, liberty and oh, yah, lets not forget the right to happiness, that assholes who don't understand what socialized healthcare actually means, which is not socialized, but universal as in all of us and we'll even let the rich assholes have it as well, so they can use other peoples money which is what they want because they also have that pesky assholeness to deal with as well, and not the ultra rich version of lies that come from that damn disorder that they can have taken care of with others money, which is what they wanted in the first place, to use others money so they don't have to spend their's while being the assholes that usually comes with the other disorder.

I could do this for hours, and some days I do..

Not because I have that assholeness disorder, but because I think it is treatable, just like the too fucking much money disorder is also treatable, and by treating these when they are diagnosed in the universal healthcare that they will use other peoples money for those very treatments, not only will there be less professional assholes out there making more money than they know what to do with, and that allows more money for others, so they don't end up with disorders because of all the stress in life that is caused by a very few keeping all the money for themselves and usually having that assholeness disorder as well, but just getting rid of the assholeness is the first step in the treatment plan for the overly rich bastard disorder that is standing in the way of universal healthcare, which they get to use other peoples money to cure themselves from, so everyone can go back to being happy and live full and productive lives instead of stressing out about life that the assholes and the overly rich bastards have caused.
Ativan

*(edit ding noise thing) I broke it up with spaces, so it is easier to read, and makes the long sentences easier to read, lol.

[Deleted]

Mar 6, 2015 0:18:04 GMT 8 Ativan Prescribed said:

One of the things that 'socialized' (not to be read as if it is some plot to take over the country and take your guns away and all that really incredibly stupid assed shit that right-wingnuts come up with, because none of that is really happening and no the states that accept equal rights for all have not turned into the gates of hell, surprise , surprise...) healthcare is so basic, that most every country that isn't run by a dictator (and even then some still have it) because it makes healthcare a national priority, rather than something that insurance companies pay out profits to those who already have more money than they know what to do with, those people who collect money, it is an actual disorder . . .

Not exactly the way I would have worded it myself, but I agree with everything said here.

[LivingTheDream]

Of course it makes sense but this is America, when do we ever make sense?

[Ativan Prescribed]

Really just wanted to write very long sentences...

[Metamorph]

hahaha, Ativan I hope you enjoyed your rant. I got the gist and agree. Unfortunately I struggle with long paragraphs and no spaces so I probably didn't get the full enjoyment.

Auntie Shan I have all sorts of documentation. Everything I could send by email I have done. The one thing I need to fax is the actual letter from the insurance cover where they outlined specifically what they will cover. I honestly don't see how the insurance company can get away with this. Because of what my policy states and the documentation I provided (and will provide) they are clearly in the wrong. Now, if it doesn't go will I be shocked? No, because the system is kind of broken. However, in this case I'm prepared to fight and point out just how broken the system is in my own small way.

I have been on my insurance's harass less since mental health parity laws came along and they couldn't limit me to a measly 10 1-hour shrink visits a year. I haven't always had the ability to fight, especially when my mental health was worse. Well fuck them. This is the new me and I'm not going to take their shit.

[Deleted]

Mar 6, 2015 12:01:18 GMT 8 Metamorph said:

 "I'm mad as hell and I'm not taking it anymore!" 

www.youtube.com/watch?v=rGIY5Vyj4YM

[Ativan Prescribed]

Mar 7, 2015 0:55:12 GMT 8 Shan said:

Mar 6, 2015 12:01:18 GMT 8 Metamorph said:

 "I'm mad as hell and I'm not taking it anymore!" 

www.youtube.com/watch?v=rGIY5Vyj4YM

I loved that movie. I really liked that it showed so many people doing just that, not as a group, but as individual things, that then made it into a group kinda thing.
For awhile, every once in a while you heard people yelling that.

Hope the insurance thing gets settled.
They are nothing but sharks and could care less about the people they get the money from, and cater to only those who are making the profits from that money.
I did have a claims adjuster who came out to look at storm damage, and he added in things I hadn't even considered.
The check sent to me was about four times what I had originally asked for.
So sometimes it does work out, and even better than you wanted. I hope it does for you as well.
I stayed with that insurance company and had everything I owned insured by them.
I didn't have any health insurance though. It cost to much for what they would have given back at the time.
My healthcare now is what I need and ask for, they know how much it'll cost if I lose it again and have to go through the same things.
it's the equivalent of universal healthcare, but I'm also lucky in that I qualify for it.
But here, people who would otherwise be jamming the ER's, are insured.
They recognized a long time ago that it's a helleva lot cheaper to take care of people up front.
Give them hell and tell them your not going to take anything less than you deserve.