“We’ve paid well over $100,000 in premiums and received almost zero health care services.”
Over the last 22 years my wife and I have paid an ever-increasing monthly premium for high-deductible health insurance policies. We did so to keep our costs low, but such plans come with almost zero actual health care benefits and our premiums increased almost 300% to $750 per month for our $5,000 deductible PPO plan in 2013.
Despite these ever-increasing premiums it wasn’t until the implementation of the Affordable Care Act that we began to finally get something for our money. In January 2014 we signed up for a subsidized Blue Cross Silver plan through the Covered California Exchange and began receiving basic benefits such as annual doctor “wellness” visits for both of us and mammograms for my wife compliments of the insurance company – things that should have been covered for all those long years we’d been paying those high rates.
But we quickly discovered that Anthem was using the ACA to increase its profits at our expense and the expense of the taxpayers. Anthem charges $1,200 per month for our plan 80% of which is paid for by the taxpayers. The subsidy is good for us, but without Prop 45 insurance companies are free to stick taxpayers with unreasonable rate hikes. This is the very definition of corporate welfare!
On February 11 of this year my wife had a medical emergency and had to be transported via the Carlsbad EMT service to Scripps Hospital Encinitas. She was assessed and treated for nearly 6 hours. Although nearly all of her other medical expenses for this incident and subsequent follow up visits with primary care doctor and recommended specialist were covered by our Anthem Blue Cross Policy, they refused to cover the EMT service charges of $1,200.
Both my wife and I spoke separately over a period of several months with a number of different customer service representatives at Anthem to try to resolve this billing issue. At different times and with different Anthem reps, we were given the following reasons for Anthem not covering this claim:
A. The first thing we were told is that there actually would be no problem for Anthem Blue Cross paying this claim, but that there had been a coding error. They told us, "as soon as the City of Carlsbad corrects this coding error this claim will be paid.”
The City of Carlsbad told us after reviewing our claim that there had in fact never been a “coding error.” We were told by City billing department representatives that the majority of their problems with insurance claims denials came from Anthem Blue Cross and that valuable administrative time is wasted because their billing department has to repeatedly resubmit valid claims that are routinely refused without cause.
B. Anthem then told us that we had used Carlsbad EMT service as a “taxi service” and that it was not actually “required” as this was not an “actual or real emergency.” They said this knowing that my wife was taken out of her local gymnasium in an obtunded state, acutely ill and unable to sit up, walk, and certainly not able to drive in her condition at the time.
C. Then we received a phone call from the Anthem claims department telling us that the Carlsbad EMT service was “out of network” and thus could not be paid. The City of Carlsbad EMT service responded to the 911 call made on my wife’s behalf on the morning of her incident. All of this occurred within a ten-mile radius of our home and the geographic base of our insurance.
The City of Carlsbad told us that there is no such thing as being “outside network” for EMT services, as these medical services are always provided to those in need strictly as a function of ones location. In this case my wife was clearly within Carlsbad City limits.
Managing this claim and attempting a reasonable resolution has caused both of us an inordinate amount of aggravation, frustration, and stress. We were finally able to get them to agree to pay $600 of the $1,200, but we are still fighting to get them to pay us the $600 they owe us. Inconsistencies in customer service and feedback from Anthem Blue Cross representatives seem designed to muddy the waters of what was clearly an emergency transport situation in our local area, which is what insurance should cover.
Our experiences with health insurance companies over the last 22 years are why we are supporting Prop 45. Relentless rate hikes, reductions in benefits, denials of valid claims, and shabby treatment are the way these companies do business. Now they are using the ACA to stick it to us and to taxpayers while growing their profits.
We desperately need to immediately place effective controls on these unethical health insurance companies, whose primary mission remains revenue enhancements and maximum profits!
Prop 45 is precisely what we the consumers need in order to be effectively protected - otherwise we are completely at the mercy of these ruthless companies.
Put the Brakes on Rates, Vote Yes on Prop 45.