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Insurance just changed rules on me ... need to decide on plan quickly

AKguyAAKguy Posts: 49
edited 06/11/2012 - 7:25 AM in Health Insurance Issues
I was just informed yesterday that my insurance company has adopted a significant new change for next calendar year.

They have decided that they will now will NOT cover the first $7,500 for surgeries conducted by non-preferred providers. This is independent of the "catostrophic limit" included in the plan. My surgeon is not a pref. provider, and in fact there are no such preferred providers in my State (Alaska) for spinal surgery. There are some orthopedic surgeons on the list, but none for spinal issues.
They would cover a share of the room charges, assistant surgeons, anesthesiologist, etc. But the surgeon fee would have to exceed the $7,500 for them to pay anything.

I am at the tail end of an "open season" at my work (ends in less than a week), and I could change to another company, but there aren't very good alternative choices. The other company I'm seriously considering has abysmal ratings (50ish percent satisfaction) vs. my current company (80ish percent satisfaction). And the alternative company only will cover 20 PT sessions per year, vs. 70-75 sessions for my current plan.

I'm currently in PT regularly (about once a week)for my cervical issues and so I'd burn through PT sessions in the new plan fairly quickly. So those expenses would be reasonably certain, whereas the surgery is more "iffy."

The current treatment plan is for me to continue PT and home therapy using a portable cervical traction device. The surgeon and physical therapist hope this will help me and I can postpone a 3-level cervical fusion. I may need that eventually, but right now I'm living day by day and watching for signs of myelopathy, or an increase in radicular pain.

So I might not need surgery this year, but if I did, that is a huge financial bite. On top of the $7,500, I'd have the other relevant deductibles, catostrophic limits, etc. So the total bill would exceed that amount.

This is really maddening. Does anyone have advice on a situation like this? If there are no preferred providers within 100 miles (in my case, there probably are none for more than 2,000 miles), would I have any basis for appeal should I require surgery?

Or if I had to travel out of State to access a preferred provider, should surgery be necessary, is it likely they would pick up some of those travel expenses for me and my family?

Assuming those are not options, it seems my choices are:

1. Switch plans, but almost certainly pay for PT expenses once 20 visits are exceeded.

2. Stay with my current plan and roll the dice that I won't need fusion surgery this year.

Gotta love our free market, deregulated health care system. Seems they can change the rules with impunity.

Any insights or advice would be appreciated !



  • It seemed they wanted to get out of paying every bill they possibly could. They refused to pay the Out of Network Ambulance bill. I guess they thought I should have given them a call as I lay on the interstate unable to move and asked about what ambulance company the bystanders should call. I am appealing. They also refused the anesthesiologist bill because once again the Anesthesia company was "Out of Network". By the time I talked to them the millioneth time about both of these bills I was way past P#####!!! The hopital I was in was in network and that was the only anesthesia available there. I guess they thought I should have either brought one with me or had surgery wide awake. I would think that if this Dr. is the only one near you that does what he does then they would pay for In Network care if you ended up having to have surgery. You have the right to appeal if they deny the claim. I hate insurance companies anymore. I'm tired of them telling us how sick we're allowed to be and what procedures our Dr.'s have to follow even though the Dr. knows they're wrong. Geez Healthcare in America sucks all the way around. Sorry. I just had to rant this morning and you opened the floor for me. I will pray for you that your continued therapy will work for you so that you can avoid surgery. Oh and you can PM me anytime. I've gotten very creative in the last few months about how to make em pay up what they owe. After all you pay the premiums. You are THEIR customer which they tend to forget.
  • Tonya42, thanks for your note and for sharing your story.

    Today was the last day of my "open season" and I ended up switching plans. I found a plan that hopefully will be OK if I end up needing major surgery. My old plan actually had more preferred providers in my area, but I couldn't take the chance of huge charges if I end up needing surgery. I'm hoping the new group is more reasonable to work with. I have to say, dropping my old company was very satisfying, after the nasty change they just foisted on their customers!

    I also submitted a message to Change.Gov, the incoming administration's website where they are seeking public feedback on all kinds of issues, ranging from the economy to the environment. Obviously health care is a primary issue for me, and for all of us on this board. I don't know if things will change, or if my comments will listened to, but I figured it can't hurt pointing out some of the flaws our current system.
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