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Good, Evil and Frustrations Concerning Health Insurance

Updated on October 3, 2014
Carol Reed profile image

Carol graduated from Indian Hills C.C. with an AAS in H.I.T and an AA in Arts & Science. A Social Media Booster for Wine Diamonds Film.

Control or Not

I had great insurance, then zero, and then mediocre and back to zilch. Now I have insurance again but the deductible is so high and some medications are extremely expensive when the insurance company refuses to pay. There should be a law against insurance companies having more control over our lives than doctors. I agree, we were at a time when some doctors and hospitals played the system. But now have we swung that pendulum excessively to the other side, giving the professionals little to zero control?

The Good Days Until.....

At one time in my life, back when I was married I had two insurances; one was a military coverage and the other a supplementary. When one didn’t pay for something the other kicked in and covered the rest. I can’t say the days were smooth because when problems arose, I knew when I had to call them to plan on being on hold for minutes maybe even hours trying to straighten out our claims. Depending on which person I was lucky or not lucky to get on the other end would determine how my claim would be handled.

Believe it or not those were the wonderful days of insurance frustration but then the divorce came. I lost both of my insurances. It didn't matter that my divorce decree stated my ex-husband was responsible for our daughter’s and my insurance. The representative with the military insurance said something like, “sorry, you’re only covered during the grace period nor does it matter if you were married for twenty years.” I contacted the supplemental insurance company. The representative said, “Sorry, there is nothing we can do. Your ex-husband was supposed to contact us within the grace period. Now if he covers you he will pay a separate policy and higher premiums on you.” My family members and other military members told me I should still be eligible for the military insurance. When I called back and asked to speak to the person in charge, she said something like, "I AM the one in charge and you don’t qualify.” I was out of luck but thank God my daughter was and is still eligible for at least one of them, thanks to the new laws.

Some may say, that’s what you get for divorcing. If you happen to have this thought process then I ask you to open your eyes, ears and heart.

Pre-existing Diagnosis

After the divorce, fast forward to the days preceding going back to school in my forties and then landing a job with insurance benefits. Yes, my mediocre insurance! Great days, until the day I found out the reason for me not being able to stay awake all these years were because I have Narcolepsy. My insurance company covered me very expensive medication until they decided it takes two tests to determine if a patient has Narcolepsy. It doesn't matter if the patient has the symptoms and the prescription helps keep them awake and able to function during the day. I was forced to take an expensive sleep study which of course some of the payment was out- of- pocket. Yes, my pocket. I took the sleep study test and not to my surprise, didn’t do well. Insurance agreed to pay for my Nuvigil. This was wonderful because this medication isn’t cheap. Time went by and then it was time for a renewal for preapproval of my prescription.

Before I go any further, allow me to give you a run down about the type of person I am. I believe all my friends, family and most of the other people that know me would agree that I'm laid back, positive, and a calm person but right is right and wrong is wrong.

Prescription Drugs

Much Needed Medication with Outrages Prices
Much Needed Medication with Outrages Prices | Source

How Do You Rate Your Health Insurance?

4 out of 5 stars from 2 ratings of Your Health Insurance

With that Said, Here is the Rest of My Story.

“What do you mean the insurance company isn’t going to approve my prescription?”

The man at the pharmacy said, “You may have to ask your doctor to write your insurance company.”

By this time my voice may have been a little high with contempt, “I’ve been taking this for a long time. Why would they refuse it now?”

“You will have to talk to your insurance company and doctor.”

I went home that day very upset that an insurance company could play with my life like this so I did what any angry person would do. I thought, what gives someone other than God, the right to determine how my future is going to play out? I sat down and wrote a letter to my insurance company. I included things like, if I have a wreck because I fell asleep behind the wheel, I give my family the right to take legal action against your company for declining me something so important to help me stay awake. I asked them if the were qualified to know more than the doctors? I asked them what schooling background gives them the right to know what is best for me to live a normal life?

I received a letter back stating they had a nurse review my records and the insurance company would renew my Nuvigil. Amen, I thought.

I spoke to my doctor at my next visit about the situation. He asked me what I told them because he had written a note ahead of me and they turned him down.

Just when a person thinks they have settled a dispute the same battle rises again. I received a letter a few months later stating I was up for review again on my Nuvigil. My heart rate rose along with my blood pressure. This can’t be happening again, I thought. I made my call to the insurance company, keeping my cool and displaying my manors, once I spoke with a real person after being on hold for a good ten minutes. I explained my situation and what I had to go through to get this approved and was reassured this would be the last time I would have to deal with this issue. My insurance would cover this medication for the rest of my life with their insurance company. Yes!

'The rest of my life insurance" ended. My new insurance will cover me having a pre-existing diagnosis. They cover don't cover anything to do with my Narcolepsy. Nuvigil medication will now cost me $556.50 for a 30 day supply. That's as much as a car payment! When my supply runs out I will be forced to take something in its place that gives me terrible headaches and doesn't work as well.

Now Get Approval and Price for Medication

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Race Against Time
Race Against Time
Race Against Time | Source

Momma Bear Against Insurance

My news was bad enough but watching my son go through an insurance situation just a few days ago pushed me over the top. Day one, my son had to go to a doctor about a cyst that burst in the “danger area" of his face. His doctor drained it, put a wick in his cheek and packed the open area. My son was instructed not to go back work for two days due to the factory he works at and having an open wound. Day two, my son went back to his doctor for a recheck and release to go back to work. He came out with orders to stay out of work the rest of the week, news that the infection is not what was suspected but instead a rare type. He was handed a prescription for an antibiotic and instructions to come back the next day for the rest of the test results and treatment. Day three, not better. He walked out with a new prescription to treat more aggressive. My son was warned this is a very expensive antibiotic and there's a possibility the insurance company will not cover it. If his insurance doesn't pay he may need to be hospitalized and get the antibiotic by IV. So now we were faced with the dilemma between the cost of medication and the hospital bill. Should he be admitted and get it by IV to knock this out faster and would it be cheaper than the medication? First we stopped at a major store in the same town as the doctor that treated him. They didn’t have the antibiotic and neither did the same store in our town, not to mention it would take three days to receive the medication. The only price they could tell him was $3,000 if the insurance wouldn't cover. We both walked out in disbelief.

His face hurt and he was nauseated. Thirty minutes from our town, he decided to call another pharmacy they didn’t have the medication either. Contacted another, they only had eight, now to find out how much this prescription would cost.

He called his insurance company and explained the situation. After going through the frustration of the automated voice that couldn’t understand him and then on hold for five minutes to be transfer to another department only to find himself on hold once again. Angry on top of sick; not a good combination and then to be told by the real person, “I’m sorry you will need to have your doctor fax in a pre-approval before we tell you how much it will cost.” He asked her about the cost of a hospital visit incase he had to be admitted. The person on the other end had to transfer him again to another department.

"Mom, I'm really tired of paying for medications that don't help."

"I know what you mean, your grandparents had to go through several throughout the years. They would get so mad about the money they wasted," I told him.

A real person finally picked up to inform him, this also needs a pre-approval from a doctor.

We arrived at the pharmacy just before closing to check out how much he would be responsible for. They contacted the doctor's office for a prior authorization and said this could take some time before we hear back. After they called, I called the doctor’s office to see if they would at least call my son if they found they couldn't get the approval before closing. That way I would know if I need to take him to the hospital.

My son's personal doctor called 15 minutes before closing. He said this could take two hours before the approval or denial comes back and this would be too late. He recommended the hospital route.

The next day, My son heard from his pharmacy. His co-pay would have been $35.00. I'm sure he was thinking the same thing I was, why couldn't this have been told to him over the phone by the insurance company.

He spent three days in the hospital on an antibiotic IV drip, had a Cat-scan, surgical consultation and is to follow-up with an Oral Surgeon after finishing up with his oral antibiotic. This turned out to be a very expensive prior authorization.

How frustrating this has all been. If he would have waited a day later to get approval, he could have died. This whole system is ridiculous. A person that has to pay for something can’t get a straight answer as to the cost and although has a prescription, has to get a preauthorization before the cost to patient is quoted. When medication can cost as much as a hospital visit or a doctor’s visit. How much is one person’s life worth?

Prescriptions

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People in Power

I know people blame President Obama but at least what he has tried to do by putting Americans ahead of insurance companies, pharmaceutical companies, and medical bills is better than allowing these rackets to continue. Isn’t it time for the American tax payers to come together and force the drug companies to stop scalping us? The new law goes some distance toward balancing the power of the Insurance companies but I feel this system still needs work. Take away the power of the insurance companies’ decisions on when a patient is allowed to know how much a drug will cost, who can or can not receive a drug, or who can be hospitalized for what and knowing how much the patient will be responsible for.

It's time to stop allowing money and greed to interfere with the basic health care, extorting people and kicking them while they are down.


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    • profile image

      Lee Collins 3 years ago

      Carol, sometimes the pharmaceutical companies will help with drug costs. I'm sorry you and your family have gone through so much. I hope your son is better now.

    • Carol Reed profile image
      Author

      Carol Clarke Reed 3 years ago from Remote

      Thank you, Lee I will try this on my Nuvigil.

    • cecileportilla profile image

      Cecile Portilla 3 years ago from West Orange, New Jersey

      Hi Carol Reed

      You are absolutely right. Health care is a basic need that all people should have a right to. Our system really needs improvement so that there is easier access to having health care needs met. I find it unbelievable that insurance companies will refuse to pay for a necessary procedure or a medication based on financial reasons.

      You should also remind your doctors to write prescriptions for generic medications as they cost less.

    • Carol Reed profile image
      Author

      Carol Clarke Reed 3 years ago from Remote

      Thank you for your comment cecileportilla. Generic medications can be great for costing less but sometimes, like in my case, I have two medications that generic is not good for me. I have heard from others that this doesn't work for them either depending on the diagnosis.

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