The Daughter Chronicles

Thursday, April 14, 2005

Insurance P.I. has Mom P.O.'d!

More insurance woes! If anyone out there currently has United Health Care as an insurance provider, do not give them up! They are the best we've encountered.

We switched insurance carriers when I changed jobs last August. My company (former) insures themselves through Private Health Care Systems (PHCS). When we first switched, we received a letter stating that our claims for Mia were going to be investigated by a private claims investigation company called "Value Check". I figured OK, whatever. They need to get information on Mia's condition.

A Value Check nurse spoke with all of Mia's therapists & providers who gave her the lowdown on the severity of Mia's condition. Claims were processed and all was well.

In January, I receive a form letter from PHCS, stating that they had fired Value Check and hired a new company called "Primax" to do their claims investigation. OK, whatever. They've already investigated Mia's claims, so we're OK, right?

Wrong. I immediately begin receiving Explanations of Benefit (EOBs), showing claims not paid due to "investigation of car accident". People, this was 2 years ago! They start sending me forms to fill out for EVERY CLAIM (and there are lots). The forms are all about accident information. Mia's medical providers begin calling me & sending letters to complain that this new company is calling them to get the same information they've already provided once. I'm really annoyed by this time, so I send the insurance company a letter, explaining the situation: accident 2 years ago, information already provided by the last investigators, etc.

Yesterday, I receive a message on our answering machine from good old Primax. The crabby sounding woman was calling to discuss my letter & assure me that everything could be handled over the phone if I call Primax--she doesn't leave her name.

I call Primax & get an equally miserable & crabby sounding "customer service" person. She looks up our file and proceeds to ask me about the accident--really what they want to know is how they can avoid having the insurance company pay claims. I'm sure this company gets commissions based on how much they save PHCS. I know I sound pissy talking to this woman, but I don't much care. I explain that the accident was 2 years ago. She wants the exact date, so I give it to her.

She starts grilling me about the name of the driver at fault, the name of their insurance company, etc. Finally, I've had enough. I tell her "Look." ***Anyone who knows me, can tell you it's a bad sign when I begin a sentence with "Look."*** "Look, my daughter has a permanent injury. Her initial care was covered by my former insurance company, and they were reimbursed by the other drivers' insurance company. There was insufficient coverage."

She jumps on that..."Oh, so your auto insurance was responsible for paying?"

Arrrrgh! If only I could jump through this phone. "My medical insurance company was reimbursed for the initial care. She's going to need ongoing care for the rest of her life, so the claims are not ever going away. End of story."

Old Crabtree CSR inserts a mumbled, perfunctory "I'm sorry to hear that." My reply is "Yeah, me too." I tell her about the providers feeling harassed. I tell her that all this information has already been provided to PHCS.

Her reply? "Well can you at least tell me the name of the other driver?" OMG & what the F@*$? I feel that little vein in my forehead throb. "Last I heard, he was in jail on unrelated charges. It was 2 years ago. I don't remember his name. He was just a 25 year-old kid".

Crabby realizes by my tone that she's not going to get anything else out of me, so she apologizes again & beats a hasty retreat. I should have been meaner, but Mia's new speech therapist was here and I didn't want to scare her.

Our lawyer told us a while back that the insurance company could not refuse to pay claims for Mia so long as we had no "pre-existing condition" to hold us back. Since we were covered the whole time, there is no pre-existing condition, so I'm not sure what they are trying to do. I'm pretty confident our lawyer would help us out if they give us anymore grief, but Jesus! I'm tired of fighting with these morons all the time.