April 8, 2011 > HealthCare...Who Cares?
By J. Dennis Wolfe
I want to share what can happen when things spin out of control. I will not reference by name any business entity or person involved so let's call the client JohnDoe. This case illustrates the importance of retaining all documents regarding your medical care.
JohnDoe had comprehensive health care cost protection coverage through a major national union. Due to personal health problems, he had to take time off from his work twice within a year and was correctly terminated each time from the employer's group billing. Fortunately, his union continued to provide coverage as a disabled employee. Employee Retirement Income Security Act (ERISA) requirements mandate this. Unfortunately, this administrative maneuver is where JohnDoe's problem began.
During both short periods of continued coverage through disability, the employee's spouse became sick; her hospital bills amounted to several hundreds of thousands of dollars. Sadly, she passed away. Claims were submitted to the union's insurance carrier and were initially paid. However, a few weeks later, the carrier rescinded those payments saying the disabled employee was not covered during the two months when his wife's medical care costs occurred. The claims-rescinding paperwork was processed despite a letter from union trust fund administrators stating he was covered continuously. The employee did nothing and the issue festered for about two years. When the hospital's collection agency prepared a lawsuit, I was asked to intervene.
Following my request for a thorough "re-review" of the matter, the insurance carrier stood firm. It turns out that they were technically correct, but they knew there was a problem. The carrier's law firm clearly knew this and did the one thing they were paid to do... stall!
My investigation found that the union was in the process of installing new software systems for enrollment administration. Installation was not going smoothly and significant administrative problems resulted including a lack of timely eligibility reports. The union did not want to admit that internal administrative issues were at the root of JohnDoe's escalating problem.
As claims were denied, time was running out. JohnDoe was about to lose his house - his only significant asset - as collateral damage of the hospital's collection agency lawsuit. Through communication between my office and other interested parties - the carrier's law firm, medical providers, and the collection agencies preparing legal actions - we were given time to sort through everything.
This case was finally resolved without legal action after almost eight months of negotiations. The carrier paid the medical charges, the hospital's collection agency stopped the lawsuit, and the medical providers wrote off what the carrier did not cover. JohnDoe retained his house and future retirement.
What saved JohnDoe was documentation. The insurance carrier and the union continued to deny liability until presented with JohnDoe's documentation. Save your paperwork. Ultimately, you are the party responsible for all cost medical expenses you receive, not your union or employer or insurance carrier.
Stay healthy. Stay tuned. Get involved. Learn what is being done. Your life now does indeed depend upon it.