Time to finish up my three part essay on health insurance from my side of the table.
Pre-Existing Conditions
I have to admit, I’m quite surprised that the term “pre-existing conditions” has become a pejorative word. Everyone thinks that pre-existing conditions is now a clause in an insurance contract that will allow the evil, greedy insurance companies to get out of paying their claim. The truth is, the term makes for nice political rallies and to get people all bent out of shape, but people don’t realize what a pre-existing condition really is. A pre-existing condition is something you already have before you took out your new insurance contract. It literally means “a condition that exists prior to…” As it stands today, an insurance company can do one of three things for your pre-existing condition. The first is nothing. They can accept what you’ve got now as an acceptable risk. As long as you are honest with the company on the application, if they accept that you have something and don’t specifically mark a restriction for that condition on the contract, they’ll cover it at dollar one, day one. The second thing the company can do is cover everything that could go wrong with you except that one problem. And they can exclude it for a certain amount of time or forever. The third option, which is the traditional option insurance companies used to use before they came up with pre-existing condition clauses, is they can outright deny you coverage. Whatever that pre-existing condition is, the company thinks it makes you an unacceptable risk and you can’t get coverage.
I’ve sold hundreds of health insurance policies, and I am always amazed how many people outright refuse health insurance coverage if something they have is excluded as a pre-existing condition. That means if they had a heart attack and the insurance company wants to exclude that, they’ll still cover you for everything except another heart attack! That’s an insurance company trying to strike a bargain with you. Twenty years ago, they wouldn’t have even done that. Today, they would think you are still an acceptable risk for everything except a heart attack. Get hit by a car: covered. Break your leg: covered. Need a hip replacement: covered. Have another heart attack: not covered. You won’t believe how many people want an all or nothing scenario. And as someone whose agency can write for every major medical carrier in his state, I assure you that the offer presented to our clients is the best offer any carrier is going to give because we check them all for every applicant. Since they can’t get any better with any other carrier, they’d rather go uninsured. You can’t do that. You’ve got to strike a bargain, or face financial ruin if you need to use your health insurance.
Pre-existing conditions are a subset of adverse selection, which I mentioned in part one. The healthiest people don’t usually want to buy insurance. Only the sickest. So if only sick people bought insurance, the insurance companies wouldn’t have enough money to pay out claims to their policyholders. The idea of a pre-existing condition clause is a negotiation between an applicant and a policyholder for insurance. Before those existed, you wouldn’t have gotten that. Believe it or not, the idea of pre-existing condition clauses is an improvement over the old system of accept or don’t accept. In my opinion, the mandatory removal of pre-existing conditions might be the best part of this health care reform, if it can be done in such as way where the insurance companies can still make money to pay for the claims of those of us who would use the care at a later time (in other words, I’m all for removing pre-existing conditions so long as it doesn’t bankrupt the insurance company I pay my premiums to).
The cost of health care
How much do you think your doctor visit really costs? $25? $15? $50? No. A doctor’s visit typically costs within the $100 and up price range. If you have insurance, you’ve only been paying $25, $15, etc. That’s because almost all major medical insurance is done through a series of doctor, clinic, and hospital networks. Every doctor’s facility pays a membership fee and signs a contract to be a part of that network. The trade-off for this is as follows: the insurance company is going to direct massive quantities of patients towards those doctors. In return, the doctors are going to slash their prices for the insurance companies. It is the same as buying any other product in bulk. As a result, we have no idea how much health care costs until we are without insurance.
As an example: There was a period of about six months between when I lost my job and started up the company I have now. During this period, I could not afford health insurance until things got stabilized. At one point, we had to go to the doctor for an injection. The bill was about $165. When we got our new health insurance, it was a high deductible plan, which meant the insurance company pays nothing until that deductible is met, we pay 100% of the insurance company-negotiated charge. The bill for the exact same injection next time we went was $13! And that was just for one tiny injection! Try to imagine a hospital charge if we didn’t have insurance. People who do not have insurance might find themselves bankrupt very quickly in the event of a medical emergency. Health insurance, if it does nothing else for you, will keep your costs low and manageable. If you go to a doctor only once or twice a year, should an emergency happen, your health insurance will save your financial life as much as your doctor will save your physical life.
Claims
I’ve saved the last topic in this essay for the last thing you use your insurance, any insurance, for. As a matter of fact, it is the one and only thing you use insurance for! Insurance companies take a lot of flak for not paying claims. And it is very easy to villainize an insurance company if they don’t pay a claim. As I mentioned in part two of this essay, an insurance policy is a contract. An insurance company will always honor their contract. They will never do any less. However, they will never do any more, either. If you ever read through your insurance policy, claims are broken up typically into several sections:
- What constitutes as claim
- How do you file a claim
- How do you collect benefits from a claim
- Why is the claim being filed (what specific health problems led to the doctor/hospital visit?)
- Rejection of claims
- Fraud/abuse
- Appeals
Most of those are pretty self-explanatory. Definitions of what a claim is, how to file one, and how do you get paid, are so basic that they need no explanation. As for the “why,” that is answered in the schedule of benefits, which as I explained in part two is not part of most employer covered health certificates and it is what leads to so many rejections. Generally, if you have an individual policy and you want to know what isn’t covered, look under “exclusions.” Usually, if what you want to get done isn’t there either specifically or in general terms, it is covered. When in doubt, ask your insurance agent.
Fraud and abuse, however, is a huge problem with health insurance. Abuse is pretty cut and dry: if you try to get the insurance company to pay for something that normally wouldn’t be paid for if no insurance was present, or if the injury is self-inflicted, that’s abuse. As a matter of fact, those are usually the first two bullet points under exclusions. Fraud, on the other hand, is a different story. From my chair, there’s two types of fraud: an error or omission by the applicant/policyholder, and an error or omission by the agent.
Let’s start with an error or omission by the client. There is a reason insurance applications are usually about ten pages long and growing. When companies underwrite, or check your medical history to see if you are a good risk, they have specific criteria they want to ask you regarding your health history. Some companies want to know about certain things going back two years, some five, some ten, some your whole life. Usually, it is a yes or no, with a request for more details of any yes answers. Usually, an insurance company underwriter will call up the client at some point in the underwriting process to re-ask a bunch of those questions again to take care of any memory lapses. But sometimes, a client will neglect to say yes to something they were supposed to. When the insurance company finds out, and they generally do the first time a major claim comes in, they’ll make the decision if that omission of information would have caused them to deny coverage to the client in the first place or not. If not, they’ll just pay the claim and say nothing. If yes, the client will get a very nice phone call from a claims manager from the insurance company asking why this information wasn’t provided at the time of the application, and if they don’t get the answers they like, your claim is denied, all your money is refunded, and your policy is canceled. That’s why it is important to tell the insurance company everything they ask for, and that’s also why they usually double-check with you in a few days, to make sure you didn’t forget anything. Usually, these horror stories about insurance companies denying claims for legitimate medical expenses on people with privately purchased major medical insurance is due to lapses in memory. It is ultimately the client’s responsibility to make sure the answers to the questions being asked are factual.
Agent fraud is another matter. I’m sorry to say it still exists, but most of the time it is committed by either the old timers who haven’t kept up with how their own field is changing, people just starting out, or those I call the “part timers.” The part timers are people who are other professionals like bank employees, accountants, realtors, or primarily in other occupations who just use health insurance as an add-on for some extra cash but don’t really pay a whole lot of attention to the product. Don’t get me wrong, there’s a lot of part timers who are a credit to the profession. But when I see fraud perpetrated by an agent, a lot of times, I see it is by a person who primarily provides a different service and sells insurance on the side. For your information, it is comically easy to get a license to sell insurance in almost any state. It is just as difficult to get a driver’s license as it is to get an insurance license. Which means it ain’t too hard. Getting licensed is only the first step. The people who actually take the time to learn their craft, keep up with the industry, and better their knowledge of the field are the ones you want to do business with. And that kind of knowledge doesn’t come from simply getting licensed.
Anyway, if an agent misrepresents the product somehow, such as lying on the application, changing some answers on the application, or telling a client that the insurance will do something that it really won’t do, it is handled much differently. First thing that will happen is the insurance company is going to contact the agent and see what they say about it. Then the company is going to call a bunch of that agent’s other policyholders with similar products. If the company finds out that this agent did in fact lie, then that agent loses their license and usually criminal charges get filed. The insurance company would usually make good on the client’s claim, even though they normally wouldn’t, and then judge whether or not to continue keeping the client or retroactively refund all premiums the client paid. At this point, however, the state insurance department is involved and the client knows they are a victim of fraud. All but one time that I’ve witnessed agent fraud the insurance company made good on the claim anyway. That’s one of the reasons I do not think the insurance companies are as evil as they are made out to be. This kind of fraud still happens, unfortunately, but it isn’t as prevalent as you think. Usually you can tell who knows their stuff. If they give you clear answers to direct questions, you know you’re dealing with an honest representative. If you get a sales or marketing talk for every question you ask, watch out.
Conclusion
That’s about it for my views on health insurance from the perspective of a health insurance broker. I hope you found these essays enlightening. There are two things I want to add about insurance in general.
Almost all insurance, at its core, is about love of someone else. Usually, the insured isn’t the final beneficiary of the insurance, their loved ones are. My house insurance isn’t about the home, it is about keeping a roof over my and my wife’s heads. My health insurance isn’t about me, it’s about making sure the bills are paid so my wife doesn’t have to worry about the quality of care I get. I have life insurance because I love my wife and I want to make sure she’s provided for should something happen to me. We are a little too young for long term care insurance, but that would be because I love my wife and don’t want her to have to take care of me if I can’t take care of myself, she can just pay the professional of her choice to do it. Keep in mind that we primarily buy insurance because it is an act of love for those we care about. All these millions of Americans that don’t have insurance; what they really don’t have is love in their life, therefore there is no need to buy insurance.
The other thing I want to mention about insurance in general. Last week, we were down in Columbus and stayed overnight for a convention. When we went out to our car the next day, we discovered we were robbed. The thief smashed in our left rear window and stole an iPod and a camera. Strangely, they didn’t steal anything else, considering there were other more valuable things in the car we were rather perplexed. The initial shock of the violation itself aside, neither my wife nor I feel traumatized at all over this. We have to buy a new iPod and camera (bought an identical camera for $20 on ebay), but the expensive damage was to the car itself, since the thief also scratched up the door. We have a small deductible we have to pay, then the insurance company said they’ll pay for the rest. So we aren’t worried. As a matter of fact, we weren’t even concerned. The total bill for everything is over $1,000, but we only have to pay $250, and we aren’t even shrugging our shoulders.
That’s what insurance does for you. It takes away our worries and concerns when a bad thing happens to you. That’s what our auto insurance did for us. And that’s what your health insurance will do for you.