Why Is It Such A Pain To Get Insurance To Pay Medical Bills?

by Silicon Valley Blogger on 2007-01-099

I’m one frustrated client. I don’t usually like to rant, but thar she blows! My most dreaded financial task ever is dealing with insurance companies, and that’s above dealing with creditors. Why? Because they’ve been holding my money hostage… for most of the year.

Here’s what I want to know — am I the only one struggling, attempting to recover our money from insurance limbo? The new year has finally begun so I’m trying to get our records in order; however, our insurance records are a complete nightmare. I get the shingles just thinking about the chore I have before me, where I’d need to rifle through the paperwork an inch thick to go over our medical and prescription records. That serves us right for using a PPO rather than an HMO so that we could seek any medical professional we so needed. For that flexibility, we are paying dearly in terms of major hassle and annoyance.

We have managed to rack up reams upon reams of medical expenses logged into two separate insurance company databases (as we changed insurance companies when my spouse quit mid-year), and now it has fallen upon me to pick through the mess and determine how much we can claim.

So far, our records show that these are the outstanding amounts against which I am owed a portion. Last I heard, I should be able to claim and subsequently get a reimbursement for a certain percentage of the total, which I’ve tallied up here:

Insurance Company Claims Amount Claimed Reimbursement Percentage Estimated Reimbursement Amount
Flexible Spending Plan At Old Company $5,428.95 Up To Flex Plan Contribution Limit $1,222.61
Flexible Spending Plan At New Company $1,933.29 Up To Flex Plan Contribution Limit $1,300
Regular Insurance Claims At Old Company $720 65% For Out Of Network Claims $468
Regular Insurance Claims At New Company $2,520 65% For Out Of Network Claims $1,638
Total $10,602.24 N/A $4,628.61

Health Insurance Bills
Well that’s not something to sneeze at! I suppose it doesn’t help that we’ve racked up a ton of transactions and that I’ve procrastinated on the claim submissions — mainly because I abhor dealing with customer service reps who have the ball in their court.

I never really fully appreciated the need for medical insurance reform (we need it like we need tax reform!) until having kids and growing a family. It’s either you get standard medical care through HMOs but care that won’t fly in the face of exotic medical conditions, or you get a PPO where you have access to the specialists you need but then you face that dreaded insurance claim nowhereland; where you get stuck dealing with a revolving door of ironically termed “care” representatives who exist to stall you long enough from receiving the reimbursements that are due you.

So I’m hoping we’ll somehow get a smidgen of the money we’re entitled to. For all that money we probably lost out on due to the insurance runaround, we’d probably be able to afford more than a nice walk in the park.

How typical is our family in terms of our medical expense scenarios? I’m not sure, though I think we aren’t that far from ordinary with life just happening to us and throwing us a curve ball now and then, by tossing us a couple of chronic conditions and causing us to land in a clinic or ER every so often (well, maybe in the case of last year, it was QUITE often). When that happens, chuck one more up to the “risk” or claims industry and a zero for the home court.

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Copyright © 2007 The Digerati Life. All Rights Reserved.

{ 8 comments… read them below or add one }

Pat Kitano January 9, 2007 at 3:47 pm

This is so true. The slow, delayed or even non-processing of reimbursements seems to be deliberate, as if ordered by management directive. This is the first time I’ve seen your complaint about the service quality anywhere, so I assume there is no consumer advocacy pushing for reform. In any case, there isn’t a regulatory body that can enforce timely processing / accounting procedures, nor can consumers vote with their feet because they may be employer insured. This is a bottomless pit.

Stephanie (mortaine) January 22, 2007 at 8:09 am

I don’t have health insurance for this very reason. I’m a 30ish non-smoker, overweight but otherwise healty. My husband is similar, but not overweight and very active. We were both slapped “uninsurable” and offered a monthly premium that would have meant the choice between health insurance and half of our housing expenses. Our biggest risk factor is driving to and from work, and I work from home now.

So, we “self insure” by tucking away money into savings, and having a credit card that has “HEALTH INSURANCE CARD” written on it in permanent marker. We use it for only one thing– emergency health care. We spend the extra money on healthy food, exercise equipment, and stress management. Not having to deal with health insurance companies has actually lowered our stress significantly.

We also lower our costs by seeking out health care providers who offer a discount for patients who pay in full, going to clinics for routine immunizations, doing routine lab work, like cholesterol and diabetes screening, during “old people day” at the local drug store. Mostly, we “tough it out” when we get sick, which is rare, unless the illness crosses the boundary between “normal hell-like flu” and into “you ruptured something from coughing too much.”

The worst-case scenario is that one of us might incur massive medical bills before becoming permanently disabled. Nothing in my past experience has led me to believe that an insurance company would help in such a situation anyway. Think about your most serious non-routine medical experience and ask yourself: did the insurance carrier just pay it, or did they reject your claim two or three times first?

Nonetheless, I do run into bizarre moments where a health provider will perform some utterly unnecessary test, knowing that it’s often routine and that most insurance companies cover it. The most recent incident involved a lab test that costs $150, and was completely unnecessary and unrequested even by my doctor. In fact, my to-do list today includes “follow up on unnecessary lab work.” This is stressful in that I have to call two people (the lab and the doctor) to find out what’s happening, but it’s not nearly as stressful as dealing with an insurance company’s customer disservice representative.

Bob Richards June 28, 2008 at 4:38 pm

Don’t know where you’re located. I am in California and 28 years ago joined Kaiser–no claim forms, no reimbursement, no payments to send in each time I get service. Join an HMO and simplify your life.

Silicon Valley Blogger June 28, 2008 at 4:48 pm


Sure would be nice, but I’ve had Kaiser HMO before and they could not resolve some health issues for my family. In the end, the PPO was a better choice, but it is a pain in the *** to deal with when it came to the insurance hassles. But we have been getting good service with our doctors, no wait times.

Are there wait times at Kaiser? I heard HMOs have their inconveniences as well.

Chumps September 9, 2008 at 6:31 pm

Maybe there’s a common medium here. An HSA will allow you to take control of your medical plan, and get a tax deduction as well.

And McCain, if elected may throw in an extra bone as well.

David April 10, 2009 at 4:47 pm

Dealing with the bills from a ppo can be agonizing! I’ve read that there is an 80 percent error rate on medical bills… in their favor!

frederick jezz January 5, 2011 at 1:13 pm

Now its very very easy for us in our state to get the claim forms, no reimbursement, no payments to send in each time whenever get the health service, plans and products. This is straight and express way to care your health!

Silicon Valley Blogger January 5, 2011 at 1:22 pm

Where are you located? It’s a complete nightmare in America, typically, when it comes to health matters. Especially health + financial matters!

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