By Stephanie Cohen, CEO
co-founder, Golden & Cohen
Insurance brokerage firm in Gaithersburg, MD
Insurance issue of the month: Think you have maternity coverage? Think again
Welcome to the first entry of the book I’ll be publishing in 2010 entitled: You gotta laugh: Life in the trenches of the health insurance business. Because we think our customers will find it useful, each month in our newsletter we’ll be posting an example of the health insurance problem that is so maddening and frustrating that we just gotta laugh at its absurdity.
Our goal, however, is to find a way to improve the U.S. healthcare system for everyone. We truly believe that by talking about this issues, and starting a conversation about what changes need to be made and how we can make them, will enable us to move mountains.
This month’s question: What do you do when you have it in writing from your insurance company that you have maternity coverage — but when you go to use the benefit, the customer service department tells you otherwise?
The situation: When our client Randy, a nurse, found out a few years ago that she was having her first baby she was thrilled. Immediately, she called the insurance company to confirm her pregnancy benefits — the fundamental first step prior to having any major test, ongoing therapies or any surgery.
To Randy, making the call was merely a formality, because when she originally purchased the policy years before she was single and didn’t opt for the maternity rider. However, after she got married, she added maternity coverage because she knew she’d someday want to start a family.
Indeed, when she made the call to the insurance company, they confirmed that she had the insurance she needed. However, after her first check-up at the OB/GYN, she received a letter saying she was, in fact, not covered.
Panic ensued, followed by a slightly hysterical call to our office. We quickly phoned the carrier, and unfortunately it took two weeks of repeated calls to them to get the information we needed. At last, we received an email from a reliable supervisor confirming that the rider had been added and she was covered.
Three years later, Randy became pregnant again. Following proper health insurance protocol, she again called the insurance company to notify them of her second pregnancy. She was told she had no coverage. Surely this was a mistake. So she hung up, composed herself, and called back.
This time another agent told her that she had dropped her maternity coverage the day her first child was born. Frustrated and confused, Randy called us. Although we’ve heard a lot of crazy insurance stories, this one seemed impossible to believe. Who would drop coverage on the day they are in delivery? Since the only person that can drop their coverage is the one who is insured, I don’t know about you, but I was not calling the insurance company during my 27 hours of labor.
We remembered, too, that Randy received an email from the insurance company stating that she had coverage prior to getting pregnant for the second time. She has saved the letter, as had we, and took it to the head of the claims department. Although the letter clearly stated that she had maternity coverage, it took three people making nine calls for four weeks to get a definitive answer that Randy did in fact have coverage and that the policy would pay for her delivery.
What we never did discover was why the coverage was dropped in the first place. Who authorized the change? And why did it take so long to resolve the matter? You gotta laugh.
Here’s how you can take control
1. When you are thinking about getting pregnant, call your broker or insurance carrier to confirm that you are covered.
2. Make sure to get the name and telephone number of the person you spoke with, the department and supervisor’s name and telephone number, and the reference number for the call.
3. Always write down the date and time that you placed the call.
4. When buying a policy, if you are of childbearing age, be certain that you are covered for maternity.
5. Get a copy of your contract and review it carefully to be sure you are covered for all the potential situations that you may need the insurance in the future.
If I were the health insurance ambassador
If I were in charge of health insurance policy, I’d make sure that every carrier clearly outline and explain what is covered in the policy. When amendments are made, the policy needs to be updated and the customer needs to be notified. I would also post these changes on the insurance company’s website using easy-to-understand language.
Too often, this information is buried in the policy and is difficult — if not impossible — for consumers to understand. I’d also make sure that carriers were required to respond to issues like Randy’s within 48 hours, as not to leave paying customers hanging. This is their health we’re talking about, and they are spending large sums of money and trusting that the insurance firms will fulfill their end of the bargain.
I often ask myself, why is this such a big problem. Is it corporate greed? Or are health insurance companies too big and bloated that no one knows what is going on. Either way, there obviously needs to be a change in the system.
The ugly truth
The reality is that for now consumers are stuck having to fight for their rights and too often their calls are not returned in a timely manner. This serves to frustrate them more, and makes the insurance industry seem like an even greater villain. For now, there’s little that can be done to change the system. The best solution for the consumer is to know what you are buying, ask a lot of questions, and have a great broker that you can trust.
We encourage you to share your insurance nightmares with us, too. Send an email to our newsletter editor, email@example.com.
ABOUT STEPHANIE COHEN
Since co-founding the Gaithersburg, MD health care benefits firm Golden & Cohen in 1992, Stephanie Cohen has helped it grow into one of the largest among female-owned companies in the Washington metropolitan region. With more than two decades of experience in small group health insurance, disability programs and life insurance, she was a finalist for the Ernst & Young Entrepreneur of the Year Award, serves on the prestigious United HealthCare, Coventry, Aetna and Kaiser Broker Council and is a member of the Womens’ President Organization, the District of Columbia Insurance Commissioner Advisory Council and The Greater Washington Health Underwriters.
She has grown increasingly frustrated with the ballooning cost of health coverage and has decided to make a change. On October 29, 2008 she hosted the DC Health Summit — a meeting of 100 top health care insurance providers, doctors, hospitals, business owners, and politicians who came together to discuss the value of workplace wellness programs as a way to lower insurance rates. Stephanie’s goal is to establish a consortium of leaders that will begin a national dialog and ultimately develop workable solutions to fix the nation’s health insurance problem.
Stephanie is a native of Maryland, and received her BS in Marketing from University of Maryland, in 1986. She has been married to Golden & Cohen co-owner Scott Golden for 20 years. They have two children.