Why You Shouldn’t Be Afraid to Talk to Your Health Insurer

Here’s a shocker: Consumers are wary of contacting their health insurers. It’s a good bet they’ve been conditioned by their own experiences, stories from friends, and the seemingly endless news stories about insurers who deny health claims. Whatever the reasons, many of the readers who pose questions to me would do just about anything to solve their health problems – except talk to their health insurers.

This may be understandable, but it can be a big mistake. Your health insurer knows more about your coverage than anyone, including the often inscrutable rules about what’s covered and how much you pay for coverage in premiums, annual deductibles, co-pays and the like.

Such confusion can be multiplied in Medicare, which has different deductibles and copays for hospital stays, doctors’ visits, outpatient expenses, medical equipment and prescriptions that are covered by the four parts of Medicare.

Another shocker? Most health insurers have been improving their customer service skills in their phone centers and on increasingly helpful websites.

Here’s a story I first wrote about last year, but it remains relevant today. It may appear to be a rare “good news” story about a health insurer, but I think it’s only rare because reporters are trained to write about what goes wrong, not what’s working the way we expect. If you want more happy-time reports, you can find plenty of them on insurer websites.

Jim and Melissa live in North Carolina. They had been covered on that state’s insurance exchange, set up under the Affordable Care Act. Their coverage was with BlueCross BlueShield of North Carolina.

Jim had just turned 65 and was told (correctly) that he needed to move off the exchange and get Medicare. So far, so good. Melissa is younger and thus needed to stay on the exchange, but she had to find a new plan that only covered her, not both her and Jim.

This would not have been a big deal except Melissa had been diagnosed with breast cancer and was facing a year of chemotherapy following a recent double mastectomy. She faced a tough road to recovery and the couple faced some big medical bills regardless of how well their insurance coverage protected them.

When Blue Cross switched Melissa to her new exchange plan, Jim says, the insurer determined that the amount she had paid toward her deductible would not roll over to her new plan. The couple had already paid her 2019 individual deductible of $6,750. Faced with the need to start over again, she would have to pay another $6,750 before her insurance coverage kicked in later this year.

Jim was distraught, and wrote me:

“It doesn’t seem right that we have to pay her individual deductible twice this year, for an individual deductible of $13,500, when the insurance is covering the same person with the same risks with the same benefits. Why does Medicare, the Affordable Health Care Act, and BlueCross BlueShield place this burden on sick, elderly couples? What is my recourse to change this sad situation?

I have already talked to Healthcare.gov about this issue. Its representatives tell me, ‘It’s not against the law. The insurance companies do it all the time.’ Is my only recourse to sue the insurer and hope that a jury will see things my way? Isn’t there any other path to contest these actions?”

When I wrote back to Jim, I thought BlueCross BlueShield had acted legally although perhaps not ethically.

Fortunately, Jim didn’t stop there. He picked up the phone and called the insurer. Good move! Here’s what he said happened:

“It turns out that, after everyone else said there was nothing I could do, I spent a couple hours on the phone with BlueCross BlueShield of North Carolina. To my great surprise and satisfaction, the agent put together a request that my wife’s individual deductible be carried over to the new plan.

Today, picking up medications at the pharmacy, I noticed that I paid nothing for my wife’s prescription. When I got home, my wife checked her account online and saw that her deductible was carried over to her new policy! I am very grateful to BCBSNC for doing the right thing. I only wish the folks at HealthCare.gov had suggested that I call BCBSNC right away.”

This happy ending to Jim and Melissa’s insurance nightmare is not a blanket endorsement for all health insurers or even that BlueCross BlueShield will always “do the right thing.”

But it is an endorsement for calling your private health insurer for questions beyond routine care. It’s usually a good thing to do so even before you need care or file a claim because doctors don’t always check to make sure your insurance covers a procedure before ordering it. While this can seem like a hurdle to getting the care you need, that’s not what I’ve seen.

The coverage that insurance plans commit to provide is not going to change all of a sudden. Just the opposite. If the care you need has been prescribed by a doctor or other licensed health professional and is covered by your policy, contacting your insurer and creating a record of your care needs can be a strong point in contesting any subsequent claim denial.

And while getting stuck in an insurer’s phone-tree labyrinth can happen, you should be able to connect with a human being eventually. What they tell you might just be helpful.