INSURANCE - CHECKLISTS AND INFORMATION Insurance Policy Checklist ACCESS TO CARE -
Will the plan cover the full range of specialized care? -
Will you have your own physician? Can you see him/her at each visit? Is it possible to obtain approval for unlimited access to specialists such as pulmonologist, gastroenterologist, or CF specialist? -
Does the plan use primary care providers, who are are not physicians, such as nurse practitioners, registered nurses, and physicians' assistants to give routine care? -
What can you do if you do not like your care, or if your primary care physician will not send you to your chosen specialist? -
Are home nursing and physical therapy visits covered? Is this coverage limited in any way? -
What services require prior approval (pre certification) from the company? BENEFITS AND LIMITATIONS - Does the plan cover medications? If yes, to what extent? Are there limitations governing the coverage of specific drug and drug treatments and infusion therapy?
- Does the plan have a "pre-existing condition" clause? If so, what length of time would that condition be excluded from coverage?
- What medical conditions are explicitly NOT covered? Are there riders or coverage waivers?
- Is there a maximum lifetime benefit or a dollar limit on care?
- What happens if you need care when you are out of state or out of the plan's area of coverage?
- Is there a penality if you go outside the network?
CLAIMS - How are claims filed? Who files them?
- How are claims paid and reimbursed? Do you have to pay up front or will the payer pay the provider directly?
- What is the procedure for filing a complaint or appealing a decision with which you disagree?
- Does this policy coordinate benefits with other policies under which you or family members may be covered?
COSTS - Is there a deductible? If so, how much is it?
- Is there a co-payment for physician office visits, prescriptions, or hospital services? If so, how much? Whatis the limit on your out of pocket expenses?
Special Assignment: Lung Patient's Insurance Terminated
Company Apologizes For Error May 12, 2003 MADISON COUNTY, Ind. -- The following is a transcript of a story from Call 6 for Help's Rafael Sanchez. It was aired Monday, May 12, on the 11 p.m. Nightcast. TIME IS HER ENEMY, BUT HOPE IS HER FRIEND.
A MADISON COUNTY WOMAN AWAITING WORD OF A DOUBLE LUNG TRANSPLANT INSTEAD GOT WORD THAT HER BOSSES HAD TERMINATED HER INSURANCE. CALL 6 REPORTER RAFAEL SANCHEZ HAS HER STORY IN TONIGHT'S SPECIAL ASSIGNMENT. RTV6's Rafael Sanchez: What most would consider an ordinary task takes an extraordinary amount of energy for Lana Hall. By the time she's done she's usually out of breath in her Anderson apartment. Lana Hall: "I tell everyone that I feel I have an 80 year old trapped in my body. I am 23 . I can't do anything a normal 23 does." Sanchez: It's been 23 year since the doctor cut her umbilical cord, but now she's attached to several feet of plastic connected to an oxygen tank 24-7.
Lana needs a double lung transplant. Hall: "I only have 20 percent of my lungs that work. Three years ago, I was playing basketball, softball, all that stuff." Sanchez: She wears the hospital pager as a necklace hoping she gets the call soon. If not --she's come terms with dying. Her will is written, her funeral plans are set. Hall: "You just get to pick out what you want to be done with yourself, different flowers, maybe some songs you want played, just little things like that." Sanchez: Due to her health conditions, Lana went from short term to long term disability with her employer Cingular Wireless. The former customer service operator says she signed up for a new health plan in November. Per the postmark, the company mailed out her payment booklet on Feb. 27. Lana got it in March and sent in a check for nearly $300 to cover premiums between November through May. Cingular returned the check, stamped void, and termimated her insurance. Hall: I talked to their manager and he won't talk to me. He left a message on my cell phone saying there is nothing he could do it's government policy and that's all. They won't listen to you. Whether its over paperwork or whether someone made a mistake, just fix it and help me. It's really scary if we don't have it." Sanchez: Call 6 e-mailed Cingular, and faxed and phoned the company. A spokeswoman says the company's April 15 termination of insurance letter should have not been sent. In a prepared statement, Cingular says "it deeply regrets that this error may have caused Ms. Hall concern during this difficult time."
The company goes on to say that it contacted Ms. Hall the day after receiving a letter from her and assured her that the benefits had never lapsed. Hall: "My insurance is back on, which is great I have 30 days more that I would have come up with the money to pay. ... I can't lie and say that I am not scared, because I am. I know I am going to go to heaven." LANA IS REMAINING POSITIVE ABOUT HER HEALTH. SHE SAYS SHE IS 20TH ON THE DOUBLE LUNG TRANSPLANT LIST. LAST YEAR SHE SAYS SHE WAS IN THE 70'S. SINCE THAT INTERVIEW, LANA WAS ASSIGNED TO A SOMEONE TO DEAL WITH HER CASE ONE ON ONE. SHE ALSO E-MAILED US TO SAY THAT SHE AND CINGULAR HAVE A NEGOTIATED AN AGREEMENT ON HER MEDICAL PREMIUMS. CINGULAR SAYS DUE ITS PRIVACY RULES, IT COULD NOT PROVIDE MORE DETAILS ON THIS CASE, BUT REGRETS IT ERROR. The following is a statement from Cingular Wireless:
"A letter sent to Ms. Lana Hall contained erroneous information about the confirmation of her benefits. Cingular deeply regrets that this error may have caused Ms. Hall concern during this difficult time. Cingular contacted Ms. Hall the day after it received a letter from her about his matter, and assured her hat her benefits had never lapsed. Cingular is of course pleased that Ms. Hall has not incurred any extra expenses. "Because Cingular abides by a strict policy protecting the privacy of its employees, we cannot provide further detail regarding Ms. Hall's case. Cingular Wireless is committed to making sure that its employees are treated fairly and regrets its error."
Silvia Manrique, Manager, Public Relations, Great Lakes Region
Copyright 2003 by TheIndyChannel.com All rights reserved. This material may not be published, broadcast, rewritten or redistributed.
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