The kind that is, if you are the sole earning person in the household, yuo can,t just have laying around.
The whole adventure begins with me at the drugstore, having to purchase over 6000$ (initially) in meds. According to the laws of the land, if our social medical system covers a drug, so must a private or group (company) insurers, first. Let us just say that the drugs needed to be bought then and now, because it was a time sensitive treatment. My wife is standing at the druggists counter. It's Friday, early afternoon. (Friday Sept 7, 2012)
She presents my medical insurance card, and of course, the insurer declines, paying for the medication.
Okay I provisioned my credit card with a line of credit of 6000$, and had to dip into my saving for the rest. No biggie, I'll file a claim and get a refund soon enough, I'll get my money back. A claim can be processed as fast as within a week, so I figure 2 weeks tops, no sweat, it won't event affect the monthly budget.
O how wrong was I.
The first signs of trouble came when I called the insurance hot line and asked for the procedure to go forward with my claim. The level one service said I would need an "exception form" filled by the appropriate medical staff, that it was a common thing. So trusting it was so, I hang up with the insurer, call the private clinic, the forms specialist nurse responds and tells us: "no, I have no clue what form the insurer is referring to." And if anything this a form the insurer should supply. Again I get on the phone with the insurance company whom I ask again, which forms they need. (assuming they need it, they should know what it is right?)
This time the person on the phone is a bit more clued-in and says what is the medication. I tell her the type of medication(s). Now she informs me that without the names according to the druggist she cannot provide which form is needed. I asked her to wait a moment while I get my wife on the line to get the names of the drugs to which she promptly responds: "no I'm sorry I can't stay on the line, please call back later". It's nearing the end of the day, the "forms specialist" nurse at the private clinic has left. The insurance company is no help, I am heading for the druggists to pay for the medication and head home. We'll sort this out later. It's Friday evening, I had it.
An important note, the druggists were baffled by the lack of response and/or accountability that both the insurance company and the clinic were demonstrating. So, they took the initiative to do some investigating and finally found the form, which is publicly available, on the government's website, I find out later. Kudos to them (Uniprix Ginette Poissant!)
Furthermore a very specific memo has been published called "INTÉRÊTS en bref #246" (also publicly available, yeah I'm a French Canadian) at Sun Life's website, outlining, the medication they now must cover. Nevertheless they insist I must get the form filled out, so I do, on Tuesday morning, the 11th (my wife is in person at the Clinic). The nurse charges 30$ (which I believe is unethical, because we are dependent on this government issued form, to file an insurance claim), and she faxes it immediately to the insurer.
On the next day, (12th) I diligently call in, to Sun Life, to make sure it's all in order. The gentleman on the phone says they have received the fax and that all is OK. I specifically ask, "is there any missing information or documentation to proceed with the claim?" He responds that they have ALL THEY need to proceed. And an "answer" will be mailed to us, concerning the exception filing. Keep in mind the #246 memo above.
Five days later (17th) (oh because we were lucky, because they allow a week [sarcasm]) we are without news, so I call in and enquire. The line one service rep tells us, it has been filed as a refusal but cannot tell me on what grounds and that the claim is closed. I try to get an explanation, but the best he is willing (or able to, I don't care) to say is: you might have to re-file and supply more information next time. So I ask, what information, can I get, that was missing? Again, like a pre-recorded message he says, I can only say that you will know when you get the letter in the mail (which can arrive as late as next Monday!) So at my insistence to know whats going on, he suggests to speak to a supervisor: to which I am transferred.
The supervisor that comes on the line isn't any more helpful, and as a matter of fact, she lies outright to my ear: they (sun Life's agents) cannot disclose the information because the letter is from a "doctor" (suggesting the person evaluating our case was an M.D.) and they, the support agent and claims people, are not allowed to see client-doctor privileged info. Which made sense, at the time. But a lie, I say again. In any case, the agent says that I can follow up, once the letter received with another supervisor. All I have to do is ask for one next time.
In fact the letter arrived early that same afternoon, and nothing about the person signed it suggested that they were an M.D. and in fact they are just a "controller" according their title. Hence the lie.
Nevertheless, it explains that the case is still open (lie #2 from the previous staff member I spoke to, earlier) and that they require the DIN (drug identification number) for each medication and a "reason" to explain what the patient needs it. Again the professional that filled the form and the professional that received (or reviewed it ) had both failed at this. Since the nurse at the clinic was more "accessible" we opted to see with her how we could re-file and she agreed to re-file (no charge) with the DINs and a note that explains why the drugs are needed. We are now the 24th. and the doctor at the clinic prescribes another 2000+$ of medication.
I am obviously concerned that this will degenerate further, so I call up the insurance company once again and ask to speak to a supervisor. I find out first that they didn't receive the fax. However (and this is a turning point, the supervisor I get, leaves me her direct line (extension) a reference number and a promise to follow up quickly, considering the amounts now in order. I call up the clinic and explain the case, the nurse giggles "come on, what's going on, I sent the fax and got a confirmation receipt". Nevertheless, she faxes it again.
Late that afternoon, the supervisor at sun life finally confirms that all is in an that it will be processed as diligently as possible.
Friday, the 28th at around 4 P.M., the supervisor calls me and explains that the case has been reviewed and that (some) of the drugs should have been paid for outright (sigh) and that the others were now "approved". However, she informs me, the actual client-claim form is missing. I said, what claim form, I called in on the 12th to make sure all was sent in and in order and now (it's nearing the end of the month) you tell me I am missing forms, again?! At this point I am cursing in my beard. This supervisor has been nothing but helpful, but I'm thinking, there's no way I'm going to get this to her before the end of the day, and I don't, the fax was sent at 19:30hrs (approx) on the 28th.
Monday 1st of October, I call in, leave a voice message to the supervisor. I'm trying to follow-up. I get a call back at 15:00 hrs, no fax received. Again we have a confirmation, nevertheless it gets "lost" in the system, again. UNBELIEVABLE!. So while I have the supervisor on the line I fax it again, myself, from work. At 15:45, the supervisor confirms that she received it and proceeds in telling me she will do all she can to have this filed ASAP. She promises to call back when it's done.
It is Thursday, the 4th of October. 14;00 hrs+. Still nothing.
In a few days, my credit card company will be charging me 19%, if I don't pay them back. So I stand to lose 1500$+ if the insurance company doesn't pull through before Monday.
And you know what? no one is accountable in this entire adventure, but me. There is no mechanism short of a lawsuit to ensure that there is any kind of liability for the lack of diligence it this affair.
It is upsetting, unfair and simply repugnant.
It is the equivalent of paying for a parachute for nearly 25 years now (being employed means paying for private insurance, by law) and when you pull the cord all kinds of hoops need to be jumped through, none of them very timely and the ground may still hit you in the face.
Oh, and too bad about the money you put in in your insurance all your life, 'cause in fact you are assured of nothing, really.
What could have gone differently:
- Better training with the agents (easy call here).
- From the first call in, a reference number (ID) should be assigned. That ensures a common line for all follow-ups. This identification number should allow to trace any documentation, calls, faxes or forms reviewed or submitted in a case.
- I cannot believe I am the first to have claimed these medications and I am NOT!. There should be a clear outlined procedure that went along with memo #246. what forms are needed and so on. I cannot believe this is not in their knowledge base. Furthermore, the memo wasn't a week old, it should be fresh in memory! If I can find this memo on your own website, then I assume an employee should, as well, if not better!
- Record all calls, period. Accountability at the first and second level response will greatly dissuade misinformation or patronizing.
- It's the 21st century, why must I rely on snail-mail and faxes. All should be done online. everyone can submit PDF documents, at least make it a darn option! I for one am very aware of the high level of competence and ingeniousness of the I.T. department at Sun Life.
- No matter how the file is sent in, make sure it is trackable for the client. Web/phone/mobile. Whatever. This way we won't keep calling to follow up in the first place!
- Network/inbox faxes are unreliable?, so don't make us rely on them!
- Have links to related forms on memos or claims. Use the power of basic HTML. If we try to file a claim online and cannot, make it Darn clear where to get the forms and for what.
But what is the moral of the story, if any?
Insurance companies have no real interest in being diligent. As a matter of fact, the longer they can hold on to your money, the more they can play with it and potentially make profits with investment interests. So one must do all they can (and perhaps it will still fail) to be sure about everything when dealing with them.They have every interest to pay you as slowly and as less as possible.
Another thing to consider is that insurance companies don't really compete. Maybe a bit on a one on one scale, but where the big bucks are, no. Anyone in managerial positions with decent size companies will tell you that there are cartels between the big insurance companies and if your employer tries to get a squeeze on them for any reason (like getting a better quote or dropping them after the first year term for poor performance) the "word" will spread out quickly and other insurance companies will refuse to insure the company's employees until the company plays ball!
Once an account manager of an insurance company has you face to face in his private office, he will tell you this to your face, it's all off the books so it's OKAY! And since having a private group company insurance is required by law, well insurance companies are the spider in the web.
They can lipserve that they are sorry or embarrased by a delay or a "situation" but they invest millions in better tools to improve their ROI and analyze better revenue channels, with the capital they get from us. We are the least of their concerns.
They don't even bother sending you a card for medication claims anymore, and they offset that cost, by making YOU PRINT IT!
I'd like to say "caveat emptor", here, but unfortunately I don't see how one can beat this system... however I must say, public enquiries are getting very popular these days with aspiring politicians.
To be continued.
