People will buy health insurance because it is supposed to be a form of protection. It helps individuals and families be able to pay for the healthcare that they need. Unfortunately, some insurers are approving certain treatments or surgeries, and then are reversing their decision. This leaves the consumer stuck having to pay for the entire bill.
It is called a reversal. This is the term used when a health insurance company abruptly changes its mind about covering a treatment, surgery, medication, or doctor’s visit that it originally approved coverage of. When this happens, it means that the insurer has basically decided to “drop the ball”, and force their customer to pay for the entire cost of the health care they received.
To me, this seems like an extremely dishonest practice, (not to mention a horrible way to treat paying customers). Some insurers, like Blue Cross have become notorious for pulling this sort of “bait and switch”. That insurer likes to find “loopholes” that will enable it to change its mind about covering something. For example, they like to approve of coverage for a cancer treatment, and then later, insist that they will not cover it because the treatment was “experimental”.
From the consumer’s perspective, a reversal can be shocking. A person discovers that he or she requires surgery, cancer treatment, or a visit to a specialist. In other words, the person needs the type of health care that tends to be very expensive to pay for. The person’s health insurance company initially agrees to cover what the patient needs to receive.
The person then goes and receives the necessary health care from a doctor or hospital. The health care provider sends the bills to the person’s insurer. Suddenly, the insurer decides to reverse their decision about covering the specific form of health care that they originally agreed to cover.
By now, the treatment, surgery, or doctor visit has already happened. In most cases, the health care provider ends up coming to the patient, and expecting the patient to pay for what the insurer suddenly decided not to cover. There is no way for the consumer to have had any idea that this would happen, and therefore, no way to plan for it.
There are only a few things consumers can do to protect themselves from getting stuck with an insurance reversal. You can talk with your doctor, before you have the surgery or treatment, and make sure that it has been approved. There is potential that your doctor has received a promise from the insurer that the treatment would, in fact, be paid for.
Or, you can attempt to push your insurer to cover what it said it would, after a reversal has happened. Keep submitting appeals through their system, until you get a solution that is in your favor. It also doesn’t hurt to get a lawyer involved, to deal with the insurer on your behalf.
Image by librarianishish on Flickr