Insurance problems after surgery

meredith_123
on 10/22/11 7:39 am - Waterford, MI
I got the EOB from Priority health today.  Was shocked to see they are showing I owe the hospital $5,700.  I got the surgery pre-approved & paid my $1,000 co-insurance to the doctors office.  Now they are saying that I've reached my lifetime max for charges and they rejected them. Not sure how that is possible, I've only had this insurance company for about 3 years.  This is the 1st surgery I've had with this insurance.  I have no idea what I'm supposed to do, there's no way I can afford to pay this.  My policy stated that I was responsible for the $1,000 co-insurance and that the rest is covered at 100%.  I'm trying to not let it bother me this weekend since I can't talk to anyone at the insurance company until Monday.  How does this effect my insurance going forward?  Do they just stop paying for everything?  I'm so confused about this.

Seeing as it's Saturday, I couldn't call there to ask any questions, but I did send a message to customer service. 

Has anyone else experienced this after they had their surgery?  I don't know what the lifetime max is for my insurance and couldn't find anything about it on their website.  Does stuff they pay out for my kids count against my max?  That's the only way I could understand we could get anywhere near a max is if it's combined for the household.
  5'5" -- HW 275/SW 246/GW 130/CW 157      
Ms. Cal Culator
on 10/22/11 9:49 am - Tuvalu


Can you find your policy online...so you (we) can read the small print?



Ms. Cal Culator
on 10/22/11 10:04 am - Tuvalu


I found it...Go here and see how you fit into these descriptions.

www.priorityhealth.com/employer/health-reform/lifetime-annua l-limits.aspx
meredith_123
on 10/22/11 10:30 am - Waterford, MI
Thanks.  Well my surgery was on 9/12, so it would fall into the year that says there's a $750,000 limit.  I couldn't possible be anywhere close to that.  Guess I'll just have to patient until Monday and call them to argue this.  Other than the 6 month pre-op diet, annual check ups and lab work, I really haven't used my insurance for much.  Even all the medical stuff for my kids is less that $100K, so I'm hoping it's just a mistake.
  5'5" -- HW 275/SW 246/GW 130/CW 157      
Renfairewench
on 10/22/11 11:18 am
Revision on 08/10/09 with
I'm pretty sure about this, but you might want to look into it further, but  Obama's health reform changed the way insurance companies can practice. Lifetime limits on insurance policies was one of the things that insurance companies can no longer have. This is what I found out. Now, I don't know if this applies to you, but it might. In which case you can so fight it. Here is where I got the below info from: http://www.kaiserhealthnews.org/Stories/2010/June/22/Documen t-Patients-Bill-of-Rights-Fact-Sheet.aspx

Today, the Departments of Health and Human Services (HHS), Labor, and Treasury issued regulations to implement a new Patient’s Bill of Rights under the Affordable Care Act – which will help children (and eventually all Americans) with pre-existing conditions gain coverage and keep it, protect all Americans’ choice of doctors and end lifetime limits on the care consumers may receive. These new protections apply to nearly all health insurance plans.1

How These New Rules Will Help You

-- Stop insurance companies from limiting the care you need. For most plans starting on or after September 23, these rules stop insurance companies from imposing pre-existing condition exclusions on your children; prohibit insurers from rescinding or taking away your coverage based on an unintentional mistake on an application; ban insurers from setting lifetime limits on your coverage; and restrict their use of annual limits on coverage.

-- No Lifetime Limits on Coverage. Millions of Americans who suffer from costly medical conditions are in danger of having their health insurance coverage vanish when the costs of their treatment hit lifetime limits set by their insurers and plans. These limits can cause the loss of coverage at the very moment when patients need it most. Over 100 million Americans have health coverage that imposes such lifetime limits.

The regulation released today prohibits the use of lifetime limits in all health plans and insurance policies issued or renewed on or after September 23, 2010.

-- Restricted Annual Dollar Limits on Coverage. Even more aggressive than lifetime limits are annual dollar limits on what an insurance company will pay for health care. Annual dollar limits are less common than lifetime limits, involving 8 percent of large employer plans, 14 percent of small employer plans, and 19 percent of individual market plans. But for people with medical costs that hit these limits, the consequences can be devastating.

The rules will phase out the use of annual dollar limits over the next three years until 2014 when the Affordable Care Act bans them for most plans. Plans issued or renewed beginning September 23, 2010, will be allowed to set annual limits no lower than $750,000. This minimum limit will be raised to $1.25 million beginning September 23, 2011, and to $2 million beginning on September 23, 2012. These limits apply to all employer plans and all new individual market plans. For plans issued or renewed beginning January 1, 2014, all annual dollar limits on coverage of essential health benefits will be prohibited.

Employers and insurers that want to delay complying with these rules will have to win permission from the Federal government by demonstrating that their current annual limits are necessary to prevent a significant loss of coverage or increase in premiums. Limited benefit insurance plans – which are often used by employers to provide benefits to part-time workers — are examples of insurers that might seek this kind of delay. These restricted annual dollar limits apply to all insurance plans except for individual market plans that are grandfathered.



 

                   HW (pre RNY) 430 HW (pre DS) 302 / SW 288 /
                          Lowest weight 157 / CW 161
GW 150
                "I'm just one stomach flu away from my goal weight"
                                       
meredith_123
on 10/22/11 11:31 am - Waterford, MI
thanks.  The link Ms. Cal Culator posted above from my insurance company talks about this.  They do still have annual limits in place until 2014, but the lifetime limits are gone.  So I guess they just screwed up my claim.  Hopefully I'll get it all straightened out on Monday.  I just hate having to waste my time calling them.  Seems like every time they mess up a claim, I spend at least an hour on the phone with them.  I find it so frustrating.
  5'5" -- HW 275/SW 246/GW 130/CW 157      
Renfairewench
on 10/22/11 12:45 pm
Revision on 08/10/09 with

It's likely a mistake, but even if it isn't this says "This minimum limit will be raised to $1.25 million beginning September 23, 2011"  so unless you went over 1.25 million you would still be covered.

 

                   HW (pre RNY) 430 HW (pre DS) 302 / SW 288 /
                          Lowest weight 157 / CW 161
GW 150
                "I'm just one stomach flu away from my goal weight"
                                       
meredith_123
on 10/23/11 1:23 am - Waterford, MI
Well customer service replyed to my email & stated that I am responsible for the full $5,700.  They said there is a $25,000 lifetime max for treatment related to morbid obesity.  I'm going to call tomorrow.  I never saw anything written about this in the policy that showed how this is covered.  It just talked about the $1,000 co-insurance that I had to pay & then that the rest was covered at 100%.  If there's a max to the covereage, shouldn't they be required to put it right there? 
I have to leave, I'll look for that later and post a link.
  5'5" -- HW 275/SW 246/GW 130/CW 157      
Renfairewench
on 10/23/11 1:45 am
Revision on 08/10/09 with
As I stated above, you might want to look into lifetime max for treatments as I do believe that the healthcare reforms has eliminated that rider. And yes, if there is a max coverage for a certain procedure then yes, it should be right in your benefit documentation.

Maddie
 

                   HW (pre RNY) 430 HW (pre DS) 302 / SW 288 /
                          Lowest weight 157 / CW 161
GW 150
                "I'm just one stomach flu away from my goal weight"
                                       
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