Insurance

Nothing can be more infuriating than spending hours grappling with medical bills and insurance claim forms, only to have the claim rejected weeks later.
Unfortunately, now, insurance companies re seizing every opportunity to deny claims in their attempt to hold onto their money for s long as they can. The aim of consumers would be to get their claims paid … get them aid promptly … and get them paid fully.
But these days, you have to be a savvy consumer who knows just how to play the game in order to accomplish those seemingly sim­le goals.
Here are some suggestions, gleaned from ty decades of experience in dealing with insurance companies, for how you can beat them at their own tricky games.
Know your policy. All too often, people just don’t know what their policy covers. Take the case of parents of a one-year-old who submit bills for their toddler’s ear infections, inoculations and other “well baby” care. The policy pays for treatment of the ear infections, but denies payment for the other care, saying it only provides well baby care for the first six months of the child’s life. Instead of simply accepting the denial, the parents should check their policy. A growing number of plans now provide such coverage until the child reaches the age of two, and some will provide it until the child reaches the age of five or six.
• Keep a log of your claims. A growing number of companies are using every flimsy excuse in the book to delay paying a claim. They’ll say they never received it, that they re­ceived it without any medical bills attached, or minus your signature. Don’t assume that no news from the company is good news. Keep track of the date you submitted the claim and the amounts involved. And always keep copies of your bills in case the company says the claim was lost in the mail. That way, you can resubmit the claim with a minimum of hassle.
Contact the insurance company if you’re not paid within four weeks. Thirty days from the time you mail in a claim is a reasonable turnaround time for payment of a routine medical expense. By contacting the company after that time, you’ll know whether there are any administrative problems with the claim… and let the company know that you won’t stand for unreasonable delays. If you still don’t receive payment, then follow up again in two weeks asking when the claim will be paid. Try to get a commitment as to when the claim will be paid. Also get the name of the person you spoke with. Note: More extensive procedures, such as a heart transplant, may take longer for a company to process.
Beware of coding mistakes. A common problem arises with the five-digit procedure (or CPT) codes that reflect the treatment you receive from a doctor. It’s not unusual for an insurance company clerk to enter an incorrect CPT number into the computer. Result: You are reimbursed the wrong amount, or even denied coverage. One way to spot this is to compare the insurer’s code (if it is shown on the statement of benefits form) with the code on the doctor’s bill and make sure they match. But some insurance companies don’t divulge these codes, and may instead say something like “diagnosis does not cover that procedure.” This language should alert you to call the company and ask that it provide the codes for the procedures performed and the codes for the procedures actually reimbursed.
Beware of down-coding. If multiple pro­cedures are performed at the same office visit, a company may mistakenly assume that less was involved than actually was the case.
Example: You visit a dermatologist to have five moles removed. The company might re­imburse for the cost of having only one mole removed. Solution: Compare your doctor’s bills with the insurance payment to be sure the company considered all the charges for treatment rendered at that visit.
Beware of a lowering of what had been considered a “customary and reasonable” fee. Typically, companies will only pay the pre­vailing fee in your area for a given procedure. But sometimes a company will unilaterally decide to cut what had been considered cus­tomary and reasonable… and thus reimburse you less. If you’ve been undergoing the same procedure for a while—say, you get regular allergy shots—you will instantly know whether a company is trying to shave its reim­bursements, and you can complain.
If it’s a non-routine surgical procedure—say, removal of your gallbladder—you may have to do some research before you go ahead with the treatment. Ask your physician what he will charge, and then call a few other doctors to find out their fee schedules. As long as your physician is in line with his peers, you shouldn’t have a problem. But if his fee is much higher, you might tell him that your company will pay only the prevailing fee … and ask him whether he is willing to accept the insurance company reimbursement as payment in full. If not, you may have to cough up the extra money yourself, or find another surgeon.
Beware of a denial because a treatment is considered “experimental.” Some insurers refuse payment for bone marrow transplants, routinely used for patients with leukemia and melanoma. They maintain the treatment is experimental. In such cases, it may be neces­sary to go to court in order to get the insurer to pay up. There’s often a two-year lag be­tween the time the medical community starts using a new procedure and when the insur­ance company agrees to cover it. Sometimes your doctor can shorten that span by inter­ceding on your behalf and presenting an insurer with medical testimony and literature that attests to the efficacy of a particular pro­cedure.
Don’t take no for an answer. If you feel the company made a mistake in processing your claim, by all means call and complain. If the person with whom you speak dismisses your arguments, ask for a review of your claim. Typically, a review is handled by some one other than a claims clerk and should take no more than four weeks. Often, just having a second opinion will resolve the problem.  Many of these decisions are arbitrary judgments.
When you call your company, always keep cotes on the date and time you called, with whom you spoke, the telephone number at which you reached the person and what transpired during the conversation. This will How you to keep tabs on the progress of your claim.
Example: If you haven’t received payment , your notes should indicate whether Mr. Smith said he would get back to you in 48 hours, or whether he asked you to provide a more detailed bill with a diagnosis. If Mr. Smith fails to contact you within the agreed-upon time, you should gain contact the company, this time by writ-rig to his supervisor.
• Go to court if necessary. If, after all your efforts, a company still resists paying a legitimate claim, it may be prudent to take legal action. For smaller claims, you can sue in mall claims court and act as your own attorney. For larger claims, consult a lawyer or independent claims adviser. Often, simply the notice of a court action is enough to spur a company to settle.

Best life insurance buys are from insurers that many consumers have never even heard of. The insurers don’t advertise widely and don’t use commissioned salespersons. They pass those savings on to buyers. USAA and Ameritas are the life insurers in this category tha offer a full line of products nationally on no- or very low-commission basis.
Both companies have strong financial ratings.

Given the skyrocketing costs of medical care and health insurance, it is particularly important to make sure you receive the bene­fits you’re entitled to … and to minimize the expenses for which you are liable.
The primary federal health-care programs are Medicare … and Medicaid—for the needy.
Other government programs, for which fewer people are eligible, include Veterans Administration (VA) benefits and Supplemen­tal Security Income (SSI), which assists the low-income aged, the blind and the severely disabled.
Medicare and Medicaid aren’t charity pro­grams. They are tax-funded insurance pro­grams you have paid annual premiums for—through Social Security—and that you are entitled to. Most beneficiaries of Medicaid, which now covers half of the US nursing-home population, have paid premiums for most of their working lives.
Even with an employer-provided health insurance plan—and we recommend you keep any plan you have—you should enroll in Medicare Part A (hospital insurance), when you turn 65 … and purchase Part B (doctor insurance) within three months of your 65th birthday. Otherwise you will have to pay an additional 10% premium for every year you wait. Enrolling keeps that cost to your employer down and maximizes the benefits of your existing plan.
Medicare was never intended to cover all of its beneficiaries’ health costs. Everyone’s
share is rising. Today, the elderly spend up to 20% of their income on health care, even with Medicare. The Medicare premium rises every year, and in 1988, the Part B section rose a staggering 35 % and is still rising.
Money-saving solutions: Make the most of Medicare. Make sure you have supplemental private insurance (medigap coverage) … and try to keep all medical costs as low as possible. How to get the most from Medicare:
Maximize your coverage by tuning into Medicare’s best-kept secrets…
Doctors’ fees are very negotiable. A doc­tor who accepts Medicare assignments agrees to accept the fee that it pays for the procedure or treatments provided, and handles the paperwork. You remain responsible for your deductible and 20% co-payment.
Only 40% of doctors accept assignments for all of their Medicare patients. But 70% accept assignments for some of their patients or for some services. So it is up to you to persuade your doctor to accept Medicare assignments on all of your bills.
Helpful approach: “I believe that Medicare pays a fair rate, and I hope you will respect my request, as I cannot afford more than the 20% co-payment. However, if you do not accept assignments, perhaps you could refer me to another practitioner who does.” Doc­tors do not like to lose clients. Most people who take the trouble to negotiate assignments are successful.
You never have to pay more than the Maximum Allowable Actual Charge (MAAC) for any service, even if your doctor does not take assignments.
Medicare has set a maximum fee (MAAC) for all services that doctors who do not take assignments may charge Medicare patients. To find out a specific MAAC, call the Medicare carrier in your area. If your doctor bills you for more than the MAAC, neither you nor your insurance company has to pay the difference.
Example: Your doctor charges $3,000 for a procedure. Medicare pays $2,000 for the same procedure, and has set the MAAC at $2,500. Medicare will pay 80% of the $2,000 “reason­able cost,” or $1,600. If your doctor accepts
assignments, you would only have to pay the 20% co-payment, or $400. If the doctor does not take assignments, you must pay the differ­ence between $1,600 and the $2,500 MAAC, or $900, and the doctor must absorb the other $500. But if you haven’t bothered to check the MAAC, you may be billed for the full $3,000, less Medicare’s $1,600, and unknowingly pay the $1,400 difference.
The fact that Medicare refuses payment does not necessarily mean that you must pay. You are not responsible for any medical bill that you could not reasonably have been expected to know wasn’t covered. You must be informed in writing from an official source, such as a Medicare notice or pamphlet, that a service isn’t covered. If your doctor tells you something is covered by Medicare and it isn’t, then the doctor—neither you nor your insurer—is responsible.
You cannot be discharged from the hos­pital before you are medically able to go. You cannot be discharged because your Medicare payments or “DRG” (Diagnosis-Related Group system) days have been used up. When you are admitted to the hospital, you will be issued a form outlining your rights as a Medi­care patient. If you think you are being dis­charged too soon, request a review by your state’s PRO (Peer Review Organization), a group of doctors who review Medicare cases. The PRO will decide if your Medicare cover­age can be extended, based on medical necessity.
Shopping for medigap insurance:
Employer-provided retiree health insurance is usually as good as the available high-option medical policies, and often better. But more than five million older Americans are paying an unnecessary, duplicate insurance that they mistakenly believe supplements their Medicare coverage. If you have an employer-sponsored plan, you may not need more cov­erage. If you do not, consider supplemental insurance. What to look for: The federal government certifies medical policies as meeting minimum standards for Medicare supplemental insurance if the com­pany requests it. To check on an individual policy, call your state insurance office.

If you or your spouse changes jobs, move to another state or become self-employed, there’s a good chance that you and your fam­ily may be left without health insurance. That could be a nightmare today as medical costs continue to skyrocket.
Though not widely known, there are places to find coverage. If you and everyone in your family are under 40 and in perfect health, you can probably call Blue Cross/Blue Shield and get coverage without delay. The process be­comes harder, however, if you are over 40 … and in less than excellent health.
Smart strategy: Buy an interim medical policy. Though rarely advertised, many insurance companies write policies for up to 12 months. These typi­cally have deductibles of at least $500 and often lack the generous benefits commonly attached to company policies.
But interim coverage is usually very afford­able. A middle-aged person in good health, for example, can expect to pay $100–$150 a month for an interim medical policy.
Where to find interim coverage: Ask your life insurance company if it offers interim coverage. Many companies do, and there are also specialty insurance carriers in the busi­ness. If your life insurance company doesn’t sell interim medical policies, call the state insurance commission for names of compa­nies that do.
Limitation: Though most interim carriers say their policies can’t be extended once they expire, many actually will extend them, espe­cially if you haven’t filed a claim during the initial period.
Contact local health-maintenance organizations. In general, HMOs provide health care that is as good as or better than what most company policies provide.
The problem is that in many areas, HMO screen applicants before accepting these. Then they either reject those who have seriouse health problems or exclude the problen from coverage.    I
Example: Someone with a serious heart condition might be accepted, but coverage wouldn’t extend to their heart problems.
But don’t give up on HMOs, even if you have a serious medical problem. Many HMOs, and occasionally Blue Cross Blue Shield, have an “open season” for one o two weeks a year. At this time they accept %i tually all applicants without subjecting the to a physical. If you have doubts about beir accepted on the basis of an exam, wait for a open season (often advertised in newspape and on television).
Consider a separate policy for an exis ing medical condition. If one member 4 your family has a kidney problem, A instance, look for a general policy or a HMO to cover all but that ailment. Then buy a separate policy to cover dialysis or what ever else is needed for the kidney condition The premiums, while high, might be less than what you’d have to pay if the condition worsened.
You can find special high-risk Carrie through state insurance commissions.
State uninsurable plans. Twenty state including most of the predominantly industrialized ones, have plans to insure people who can’t get coverage elsewhere. Rates, However are usually up to 50% higher than what others normally charge.
Advantage: These plans accept nearly ever one, regardless of existing medical cone Lions. This may actually make the coveral cheap for people who have ailments that a expensive to treat.
Join an association that offers health i surance. Many fraternal and professional c ganizations—as well as some clubs, alum associations and civic groups—sell health
Insurance to their members. Coverage can sometimes be bought even without taking a physical.
Caution: Look at the policies carefully. A few are excellent, but others can be expensive—and coverage minimal.
To find out which organizations you might consider joining, consult the Encyclopedia of associations, available in nearly all public libraries or on the net. By looking up any of your special interests in the index, you’ll find a list of organizations involved with that field.
Then phone the groups to find out if health insurance is one of the benefits they offer.

One of the quickest ways to put money in our pocket is simply to review your home ­isurance policy.
Chances are, minor adjustments in cover­ge will save you hundreds of dollars a year and in the event of disaster, having the right ome coverage will probably protect the iggest assets you own.
According to the latest estimates, 80% of the country’s homeowners are not buying the right home-insurance coverage.

Finding the best companies:
Some storm victims in South Carolina are :ill waiting for their insurance settlements ionths after Hurricane Hugo struck. The situ-Jon is similar in California, long after last ear’s earthquake.
But don’t think horror stories like these appen just to victims of front-page disasters. Each year thousands of people whose homes destroyed  by fire, flood, wind or theft are dis­ayed to discover that…
They’re not fully covered for the loss.
They are covered, but they have huge ex­penditures before the insurance company finally settles.
Ironically, the best insurance companies are often the cheapest. Usual reason: They sell directly to homeowners without using agents. This eliminates agents’ fees—and often speeds up settlements.
Companies consistently rated high in cus­tomer satisfaction: Arnica Mutual, Erie Insur­ance Exchange, State Farm and USAA.
Those often ranked low: Several of the largest and most well-known insurers.
If you have doubts about a company, check with people in your neighborhood who have put in a claim. Be wary of an agent who won’t put you in touch with homeown­ers who have filed claims. Some state insur­ance commissions also have complaint data on insurance companies.

The over-insuring trap: The prospect of having inadequate cover­age scares some homeowners so much that they overinsure.

Examples: Insuring a house for its current market value. This might sound like a good idea, but it’s foolish because even serious disasters rarely destroy the full value of a home. The market value, for instance, includes the price of the lot and the foundation. These are likely to survive anything short of an engulfing earthquake or nuclear explosion.
Even if a $200,000 house is completely destroyed by fire, a policy will pay, at most, around $160,000, assuming the lot is worth about $35,000 and the foundation $5,000. The difference premiums on policies that provide $160,000 and $200,000 in coverage can easily be more than $200 a year.
• Buying a low-deductible policy. Again, this only sounds sensible. In fact, premiums are about 40% lower on a $1,000-deductible policy than on $100-deductible coverage. With savings like that, it clearly makes sense for most families to assume a $1,000 risk, especially if they put the savings into an inter­est-bearing account.
Families with low-deductible policies are often reluctant to file small claims anyway. And for good reason. Insurance companies are more likely to cancel a policy after paying several small claims than after paying one large claim.
The under insuring trap: Many people think they’re completely in­sured once they make an inventory of every­thing in the house and have it all written into their policy. What they overlook: Insuring for replacement cost instead of market value.
Example: If a sofa that you bought for $500 10 years ago is destroyed, a standard policy is likely to pay only about $200 for the depreci­ated couch. But if you’re insured with a re­placement policy, it might pay you $1,000 to buy today’s comparable sofa.
The difference between premiums on stan­dard and replacement policies runs only 10% -15 % but replacement costs can actually run much higher.
Even the best policies don’t cover homes for flood and earthquake damage. That cover­age must be bought separately. Trap: Outside of a few obvious areas, homeowners often don’t know when they’re vulnerable to floods or earthquakes.
Helpful: Federal maps show flood and earthquake risks for homes in every part of the country. They’re available through city and county governments.

Courts in many states are more likely than ever to hold an owner responsible for injuries to a visitor. That’s so even though the person was on the property without an invitation. The old distinction between an invitee (some­one asked onto the property) and licensee (someone on the property without an invita­tion) is breaking clown. Traditionally, invitees would be awarded higher settlements for damages.
Now courts in about one-third of the states ignore the distinction between an invitee and licensee and hold the property owner responsible for keeping the property safe for both invitees and the self-invited.

Unfamiliarity with the complexities of the system. The companies deal with these insurance matters day in, day out, and count on the fact that most drivers file a claim only once or twice in their lifetimes.
Wrongful denial of a claim: Always ask to the exact contract language a company is using if it denies a claim.
Example: If your policy has a $500 deduct­ible and your claim comes to only $486, the company is perfectly right to refuse payment because you haven’t yet satisfied your deductible.
But the situation may he less clear-cut if the policy language is ambiguous, with regard to coverage while driving a rental car, for exam­ple. I’ve seen companies refuse to pay claims When policyholders were involved in acci­dents while driving rental cars, even though the language in the contract does not bar such coverage.
Solution: In such ambiguous cases, point Out to your company that an insurance policy is a contract of adhesion. This means that the party that wrote the contract (the insurance company) had total control over- terms of the contract, while the party that signed it (you, the policyholder) is stuck with it. Then remind the company that the courts, over and over again, have interpreted the language of such one-sided contracts in favor of the party that did not write it. So, if there’s any ambigu­ity in the contract language about what is and is not covered, chances are that you’ll win in court—and the insurance company knows it. It simply needs to he told that you’re aware of your rights in order for it to act responsibly.
Slow payment of claims. Unscrupulous companies will take as long as they can be­fore they pay a claim. Reason: The longer they have your money, the longer they can keep it invested. Don’t accept this foot dragging.

When to expect payment: If there’s no question who caused the accident, you should receive payment from either your own or the other driver’s insurance company within 30 days. If there is a question of who was at fault, you may have to wait until the matter is settled between the two companies or between you and the other driver, perhaps through arbitration.
If your insurance company is taking too long to pay, complain in writing to your insur­ance agent and to the manager of the claims department. If this doesn’t work, contact your state insurance department. Many states have laws that mandate a timetable for claims han­dling. These laws require insurers to respond to claims, begin investigating them and reach settlement within a certain number of days.
Shaving the claim. Some companies re­fuse to “make you whole” after an accident. Typically, the problem arises with a car in good condition that is totaled. The company will usually offer the Blue Book* value of that car. But this value is based upon the average vehicle of that age and manufacture. Perhaps yours was a real gem, garaged and driven only to church once a week. If you can docu­ment that your car was worth more—perhaps through photographs, mechanics’ records, etc.—the company should reimburse you accordingly.
I am not suggesting that you inflate the claim. This hurts everyone since it drives up the costs of insurance to both good and bad drivers. Not being able to afford adequate insur­ance if your driving record is less than perfect. If you’ve been involved in several accidents or accumulated a lot of tickets, don’t automati­cally buy insurance from your state’s “as­signed risk plan” or “joint underwriting facility.” This insurance coverage, in which all insurers licensed in the state must participate, is designed for high-risk drivers who might otherwise not be able to purchase protection. This insurance often costs more than com­parable coverage for “non-standard” drivers that you might be able to buy directly from a particular company. Because it lumps together the worst drivers in a state, assigned risk coverage tends to be a scavenger’s mar­ket and a high-profit business for the com­panies that offer it. But, be careful—some “non-standard” policies are ultra high cost. Don’t pay more than the assigned risk cost. You may do better to buy coverage on the open market, especially if your violations and/or accidents were not major ones.
Signing away rights before the full extent of injuries are known. Say someone driving another car hits your car and it’s clearly his/ her fault. That driver’s insurance company may present you with a release form offering you a certain sum of money—perhaps $500. The release will state that the $500 is full payment to you and that you relinquish the right to make any further claim.
Beware: Sign such a release only if you are absolutely sure the sum covers all damages. If you were injured even slightly, don’t sign such a release. But don’t ever fake an injury in an attempt to increase your settlement—you could wind up losing your coverage. Getting duped by ” sound a likes.” Some companies that have very high rates have names that sound a lot like the names of com­panies offering low rates.
Self-defense: Comparison shop carefully to make sure you are working with a company that charges reasonable rates. Not getting the correct insurance rating. Most people haven’t a clue about how a com­pany’s underwriting department has evalu­ated them. Generally, all consumers see is a code that consists of a bunch of apparently meaningless letters and numbers. But these letters and numbers represent important data about your age… driving record… address… and other factors that determine the level of Your premiums. If the code is wrong and mis­represents your true situation, you may pay much more for your coverage than you Should.
Solution: Make sure you are rated correctly by asking the complete meaning of the code you have been assigned.
Not all rating mistakes are intentional, by the way. The person processing your applica­tion may simply have checked the wrong box.
Assuming the company offering the widest variety of discounts is the cheapest. Some companies, generally those whose poli­cies are sold by agents, can offer up to 20 dif­ferent discounts—for things from car-pooling to nonsmoking. But their prices are often higher than companies that offer just a few discounts.
Reason: The discounts area selling tool for the agents, who use them to proclaim that they’ve managed to cut the (inflated) pre­mium price to a fraction of what it would have been. Self-defense: Compare the net cost of one policy to the net cost of another.
Assuming that companies will automati­cally give you all the discounts to which you’re rightfully entitled. Recently, several states have taken insurance companies to Court for failing to give customers contractual discounts for features such as air bags, auto­matic seat belts or car alarms. As a result, the companies are being forced to repay millions of dollars in excess charges.
If you think you have not received dis­counts to which you were entitled, notify the company in writing. They should repay you for any overcharge and immediately apply the discount to all future premiums. If the com­pany doesn’t satisfy you about this, write a letter to your state’s insurance department. States tend to be strict in this area.