California Resident w/PPO needs advice

[CynCritter]

I carry personal PPO insurance. When I get my Los Angeles County I.D. Card, and purchase State legal prescriptions, am I also legally allowed to submit these costs to my medical insurance carrier? It seems logical that since my insurer has to obtain a license to operate in the State of California and abide by the Laws thereof, shouldn't they have to cover some of my presciption costs and perhaps the physician's letter and the I.D. card as well?

 

[City Indian]

Maybe on the ID card, cause Medicare pays half of the county card ID, so why wouldn't private insurers? Not the dr's visit though, and I doubt they'll cover any of your purchase costs, but wouldn't that be nice?

Why not just call them and ask?

 

[CynCritter]

Maybe on the ID card, cause Medicare pays half of the county card ID, so why wouldn't private insurers? Not the dr's visit though, and I doubt they'll cover any of your purchase costs, but wouldn't that be nice?

Why not just call them and ask?

Well ... here's the reason:

My PPO has been looking for reasons to cancel as many chronic disease-stricken policyholders as possible, since early 1998. This has been evidenced by the hundreds of policyholders who have been insured for less than 2 years when diagnosed with cancer, M.S. C.P., Chronic Fatigue Syndrome, Rheumatoid Arthritis, and other similar, long-term/incurable/life-threatening afflictions.

The insurer first authorizes all necessary testing, but when the testing proves the dreaded diagnosis, the insurer witholds payment for the tests and subsequent treatments and prescriptions, and spends hundred of thousands of dollars (and forces the insured to retain counsel) to insinuate/intimidate the insured of committing fraud to obtain a policy to cover a disease the insurer alleges the insured "was already aware of and lied about on the initial policy application form." The insured (who has been making premium payments in good faith since inception of the policy) is now responsible for mounting legal fees, while he/she is being turned over to collection agencies by the doctors, labs, hospitals, etc. who received authorization to conduct the tests and treatment, but was never guaranteed payment of same by the insurer who gave the go-ahead for the covered services, and therefore has not been paid ... and this doesn't even take into account the detrimental affects on the already compromised health of the insured,while being accused of wrong-doing, and the added stress defending one's right to proper care and treatment.

To add insult to injury, the insured (who is being wrongly accused of fraud) must ALSO pay continue to pay the insurance premiums when they are due, while he/she is being brutalized by the insuring company ... just in case the company knuckles under or the insured is eventually exhonorated and needs to have continued coverage.

In order for me to ask this arbitrary question, I must call and give my policy number and be totally identified as a bonafied policyholder, and be scrutinized by three or more in-house representatives before I'm actually connected to someone (who has - you can bet - Underwriting conferenced on the call with me, whether I'm advised of this or not) so that all the company's legal bases are covered. (It's called "CYA, Big Time!") is being counseled on how best to answer my questions without putting the Company at risk. And since MMJ is only a State recognized treatment by prescription, you can bet hand-written notes are being entered into my file about a potential for "drug abuse" ... and there is nothing in the world to stop them from arbitrarily advising the DEA that I'm a potential risk, even if the company has yet to find a reason to non-renew my policy.

You may think I'm paranoid. Yes. I have a good right to be.

Although I'm retired, I worked in the insurance industry for more than thirty years - everything from MediCal and private medical policies in the 1970s through auto and homeowners' policies in the 1980s and 1990s, to corporate insurance policies, and Umbrella Coverages, right up to the beginning of the 21st Century. I know how unscrupulous and conniving these souless companies truly are at their cores.

I also am aware that for the past 10 years my own insurer has raised my rates from $2300/year to over $12K per year, all the while decreasing my benefits and percentage of prescriptions covered -- just because of my age and my diagnosis of R.A.

They know I cannot go to any other insurer, because the bulk of my medical expenses are R.A. related; if I were to go with a different company, everything related to R.A. would be excluded entirely for the first 5 years ... and that means literally 98% would be excluded except OB/GYN-related problems, and I had a hysterectomy when I was 29, so there's NIL to cover otherwise.

To bring this up and have my policy "flagged" for potential drug abuse could create tremendous problems for me, and I have to believe that other companies are no less potentially underhanded when it comes to their insureds.

So, to answer your question in the best possible way, THESE are the reasons why I don't just call up and ask... I know how these companies look at you and me from the inside out.

 

[City Indian]

Wow i hear ya CynCritter. How about calling the place that processes the county ID card? They might know?

Or just pay the full amount to save any later headaches? Might be worth it?

 

[CynCritter]

Wow i hear ya CynCritter. How about calling the place that processes the county ID card? They might know?

I have an appointment with the County scheduled for July 12th. This question is on my list of questions, although I don't hold out much hope that an Intake Worker - especially for something as NEW as I.D. Cards - will have any profound answers...

If the rest of you who are reading this, schedule appointments, too, you might put this question on YOUR list ... perhaps the more people who ask the same questions can get supervisors and managers to seek solutions.

CynCritter

 

[City Indian]

Good luck!

 

[xwwx]

Wow, I'm really sorry to hear about that CynCritter. I don't really have an answer for your questing, but I wanted to send my regards and give some support. Mayhap one day a bunch of the people who are being screwed over by said insurer will band together and hire a good lawyer to sue them, because that is flat out wrong.