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    To Whom it May Concern re: Medical Insurance Coverage

     

    Ms. Templesman

    Claims Adjustment Supervisor

    Just Say No Health Insurance, Inc.

    23588 Cartel Parkway

    Alexandria, VA 21351-0000

     

    Dear Ms. Templesman: 

    I write in reference to Claim #1297-5576-342-22-015.

    My JSNHI group number, ID number and PPO policy code are noted on the attached claim, which has been returned to my gynecologist, "denied."

    As the monthly payments for my policy are current, my annual deductible is paid in full, and I fork out co-pays at doctors' offices as I go, I wish to file a formal complaint against your company for denying this claim, particularly when the reason offered for the denial by one of your staff adjusters is so patently absurd.

    As you will note by reviewing the file notes, Ms. Templesman, my claim for a standard annual gynecological exam was denied on the basis of a documented "pre-existing condition." As I was not aware that I had a pre-existing condition in this category, I called to enquire what that pre-existing condition might be.

    Imagine my astonishment when I was told by your representative that my pre-existing condition is listed, in this context, as "MENOPAUSE.".... 

    MENOPAUSE???? (This would be hilarious if it were not so insane and in fact, I did laugh out loud when I thought she was just an unusually good-natured adjuster who was joking.).

    Sadly, though, she was not joking. In fact, she informed me quite severely that "This is not a laughing matter."  Well, now that I've received the bill for the full amount from the gynecologist -- a bill, btw, now stamped OVERDUE -- I suppose I see her point, if from the opposite side of the lens. I agree -- the bill I've been sent is no laughing matter, especially when it must be paid by me --  a woman who is already coughing up (don't get excited now - that's not an allusion to an undisclosed medical condition I've been attempting to hide from JSNHI; it's just the figure of speech that came to mind) when I am already paying $932 per month, paid off a $2500 deductible and have a $35 per visit co-pay.

    Call me naïve, Ms. Templesman, but you'd think that since I have an annual obligation to pay JSNHI more than $13, 684.00 -- before the company will pay ANY claim I make -- that fact might  result in a quick settlement for claim of "only" $400. 

    Instead, it seems to have incited real resistance, which I do not and will not accept.  

    The larger point - the important point - I wish to make, however, is that what JSNHI seems to saying -- without actually saying it -- is that no woman who is a policy holder with JSNHI, but who has had a hysterectomy, is qualified, any longer, to be reimbursed for an annual gynecological examination. Are you then, effectively stating that, as a matter of policy -- simply because we can no longer have children -- that none of us will be approved for reimbursement for the standard screenings that detect forms of cancer, as well as other forms of infection or disease

    If so, Ms. Templesman - if this is a new JSNHI policy - then I am confused about your corporation's business plan. Why would you nickel and dime women to this egregious degree, when we, as a gender, represent over half of your customer base? It is statistically documented that your industry already charges women more than three times what you charge men of similar ages, with similar medical histories, for policies. Now, in addition to that disparity, JSNHI is prepared to not only charge women much more, but provide them with less coverage? 

    Question: are you refusing to cover annual prostate exams for men who have had vasectomies? Because if you are not denying them that essentially parallel coverage, then you might consider the bottom-line damage (sorry again for poorly-chosen phrasing) JSNHI will suffer if @ 35% of your customer base takes its business elsewhere, in protest.

     Don't think for a minute, Ms. Temlesman, that women are not prepared to do this; in fact, tell the powers that be to wrap their actuarial minds around the fact that a lot of women I know, across the country, are thinking very seriously about dropping their health insurance, altogether - not because they are indulging in fits of ill-advised pique, Ms. Templesman, but because they simply can't afford the cost, anymore.  

     Therefore, I suggest, quite sincerely, that the wiser alternative would be for JSNHI to review its policies and correct the egregious disparities between costs and coverage for men, versus costs and coverage for women. Otherwise, be advised: you will be slammed by the Mother of all class action suits, and we will ultimately win.... Or at least our heirs will win, as we ourselves may be dead, long before the claim is settled, having succumbed to undiagnosed diseases that, if caught in time, would have been relatively inexpensive to treat, and relatively assured of being completely cured. 

    In the meantime, your thoughtful response and timely correction of this denied claim will be greatly appreciated.

    Sincerely,

     

    Susan Ravenel Rutledge / 5 1/2 Legare Street/ Charleston, SC / 29401

    Comments

    Yes, the pre-existing condition is:

    a.) being female, and

    b.) over 50.

    That is some craaaaazy stuff. I thought it was bad when I had to sign a waiver for pregnancy. Who knew getting pregnant or menopause was not a normal condition of being human?

    I guess male actuaries do, as neither ever happens to them. I'm beginning to wonder if they are human. This same sort of unfair sexist nonsense goes on with birth control pills and viagara.

    I think I like Susan, quite a bit


    While I doubt people will leave the medical insurance companies in droves, since private insurance is so cumbersome and difficult to get, a portion may leave since it costs so much and pays so little.

    My own pre-existing condition of drug-managed high blood pressure raised my rates 50%, and they denied my daughter coverage (twice) for "seasonal allergies," so she has no coverage.


    While I doubt people will leave the medical insurance companies in droves, since private insurance is so cumbersome and difficult to get, a portion may leave since it costs so much and pays so little.

    My own pre-existing condition of drug-managed high blood pressure raised my rates 50%, and they denied my daughter coverage (twice) for "seasonal allergies," so she has no coverage.


    Insurance companies are run by a bunch of anti-social, mental cripples with a calculator.


    I had excellent medical coverage paid for out of my pocket because I could get a personal, individual policy with excellent coverage for less than $250 a month. And it was better than the company policy too!

    Until I was 50.

    Premiums shot up over $900 simply because of the generic health problems associated with generic population of individuals over 50 as a whole. I even sent a letter off to Harry Reid and all I got back was a generic letter talking around the subject of health care and related issues but nothing that specifically address my initial inquiry.

    I'm of the opinion there's nothing a person can do as an individual to right a wrong when the criteria you are fighting against is the generic make up of the population as a whole. The odds are stack against you.

    Also keep in mind, it's not the federal government responsibility...it's the State you live in...10th Amendment stuff is written all over health care at the state level and they're the guilty party as to why medical costs are out of control and premium prices are so high.

    Of course, health care reform just passed by Congress left the States in the driver's seat with little necessary corrections to steer their state policies in the direction the federal government would like to to go.

    I'm lucky health care in Europe is relatively inexpensive compared to costs in the states. I do take a financial hit exchanging dollars for euros, but the quality of individual care at my local doctor's office and prescription costs are easily manageable without using health care insurance.

    So what kind of HCR would there be in the US if people could easily afford to see a doctor and pay for prescriptions whenever they are sick without having to do without food, shelter and other life necessities with a yearly income of $20,000?


    Thank you, Bwak -- I think I like Susan, too. I admire her bravery, as I admire yours; both of you say what needs to be said -- without holding back -- despite the flack that may be incoming -- even though what you say is, for the most part (with some exceptions) really temperate with a strong ephasis on fairness.


    I think you've summed it up nicely, Beetlejuice.
    Thank you for pointing out not only the relevance of which state is pivotal in an individual's experience, but also for pointing out that the "new and improved" HRC does nothing to correct that wild card.
    I'm glad for you that you are in Europe, though sorry that our economic woes are working to your detriment in the currency exchange.


    Your daughter is denied coverage for allergies??? That is a new low. As is 50% higher rates for medication-controlled blood pressure issues. What does the medication cost? -- If it's Diovan, $6 per month? Sure -- that justifies 50% surcharge -- sure it does, if you are an insurance company, it's an open invitation, I suppose.
    I'm sorry, LosAmigos.


    Plenty of exceptions, no doubt.

    =D

    Thanks and right back at you. I appreciate you get the fact that I am trying my darndest to be fair.


    I am amazed that Susan can remain civil in her correspondence, considering the crap the Just Say No Health Insurance company is pulling.

    I also enjoyed her prior letter, the one to the President where she did such an excellent job explaining things, it left me understanding better the views of those less impressed with the pace of the current administration. I did not wish to join in the festivities that followed in the thread. To me, it's kind of a waste of time. I mean, there's other serious shit going on that needs attention besides who's the winner of the last fu-fu2 fight. But, I digress. :o)

    Back to the medical insurance coverage situation. I'd like to take a snark moment and say that maybe old Susan should have dragged her menopausal carcass off to the nearest ditch and just died there and thus avoid causing such an embarrassment to the noble insurance company. But, seeing as how she couldn't bring herself to make the sacrifice and got herself all fired up instead, I reckon firing a missive off to the bastards will, at the very least, make her feel less impotent in the matter. I mean, fighting the health insurance monster can suck the life out of an ordinary person and I can tell right now that was an unfortunate turn of phrase I just typed, but I can't think up another offhand. Let me just say this: Battling the Just Say No Health Insurance company is futile. They're like the Borg....the mindless Borg.

    I will be testing out the changes in HCR in the coming weeks. Supposedly, there are a few things going into effect soon, or already are, and I'm curious to see if any of them will have a truly positive effect on the quality and cost of the care of my health (or lack thereof) and the rumored benefits of my new and improved benefits. If Susan is still around after the poking and prodding stops, maybe we can compare notes.


    It's the Federal interest rates being at zero percent that makes to dollar so cheap. Once it starts to rise, the exchange rate will get back to parity with the euro...1-to-1.

    One thing I forgot to mention is my quote for medical attention by a local physician is extremely affordable while the costs for care at a hospital, such as surgery, would be hard to swallow..that's when you really do need health care insurance to cover your medical costs.

    But the costs for surgery in a US hospital isn't pocket change either so it works out about the same. That's where I need health care coverage the most. Colds, fever, allergies and minor injuries and so forth aren't too expensive to handle with disposable income.

    Just think how much more efficient the US medical service to the public would be if everyone could afford to see a doctor for life's minor inconveniences and it didn't force them to consider which bill not to pay.


    I agree battling them is like battling the Borg.

    Hopefully there will be some recourse, some place to direct something like being denied coverage for a pre-existing condition such as 'being a human being'. Because the Borg will point out that human beings get sick, injured, diseased, pregnant,etc. and that can require a lot of medical care. And since the health insurance Borg are in the business of making money, they find these pre-existing conditions a drain on their profits which won't be tolerated.


    Hey Flower --
    My friend Susan has no more desire to die prematurely than any of the rest of us. But, on the other hand, the ongoing stress of trying to find the money to pay their usurious policy rate and deductibles, which is exponentially exacerbated by the stress of repeatedly dealing with adjuster insanity, just might cause her untimely demise by stroke... instead of "slowly turning green," as originally envisioned. (Note: "slowly turning green" is in quotes in deference to a friend of her mother's who once said, when asked why she was taking flying lessons at age 70: "Oh, I think it would be so much more elegant to crash than to slowly turn green, don't you?"

    You are, of course, quite right about the tilting at windmills aspect of fighting the insurance monster. I said much the same to Susan, but she felt she had to write on protest, anyway, just to have done it.

    I, on the other hand, have been busy being scanned for this and that, scheduling as much repair and maintenance done as I can get approvals for before my Cobra runs out in December. By December, if nothing is currently pinging the danger zone sonar, then I will do without health insurance until 2014. Because -- pardon the use of the word -- it is my only "option."
    A private one, because the public one didn't happen. ;-)


    We got what we "paid" for, in votes that is. What's to be done ? Just complain, or lie down and die in one way of another if you're sick, or maybe figure out some kind of political move.


    Dear Ms. Rutledge:

    We are in receipt of your letter to Ms. Templesman, our Claims Adjustment Supervisor, dated July 25, 2010. You are correct, menopause is a listed pre-existing condition. Pre-existing conditions are excluded from coverage.

    We regret your decision to look for health insurance coverage elsewhere. We do want to continue to be helpful, however, so I have attached a list of all health insurers authorized to do business in Virginia.

    I note that your current premium installment is 12 days past due. To insure that there is no gap in coverage, you will want to pay this overdue premium installment promptly. As you know, a coverage gap may result in additional pre-existing condition exclusions from your new insurer.

    Sincerely,

    Sarah Sowrong, Ass't to the Director
    Customer Relations

    Encl: Health Insurance Companies Authorized to Do Business in Viriginia

    CC: Ms. Templesman

    --

    HEALTH INSURANCE COMPANIES AUTHORIZED TO DO BUSINESS IN VIRGINIA

    1. Just Say No Health Insurance, Inc.
    2. Market Rate Health Benefit Plans, Inc., a wholly-owned subsidiary of JSNHI
    3. Outta Pocket Health Care Corp., a majority-owned subsidiary of JSNHI


    HA! Truly laughing out loud, Red Planet. I am not only delighted by the complete character credibility of Ms. "SoWrong," but also by the list of companies licensed to sell Susan a new policy, all of which are, of course, one and the same.

    Absolutely fantastic. Just one quibble:

    "Dear Ms. SoWrong:

    Thank you for taking the time to address my concerns so promptly.

    I appreciate your clarification of what constitutes a pre-existing condition as I thank you for including a list of alternative, "competive" providers.

    I must point out, however, that you are mistaken in thinking my premium is overdue. If you will, please check with accounting so that you can confirm that, at the time my policy was approved, it was approved only on the condition that my monthly premiums be paid by automatic withdrawal from my bank account which, in turn, was linked for back up to my credit card.

    I protested that requirement, as it seemed unnecessarily invasive of my financial privacy, but I was told that it was a company policy required of all new customers.

    Nonetheless, I do appreciate your attention to detail.

    Sincerely,

    Susan Rutledge Ravenel"


    Funny, Red, but I have yet to experience an insurer who would not (at least) threaten to cancel insurance permanently if payment is not received by the first of the month.

    And don't forget to submit your HIPPA form showing proof of no-gap medical insurance. Otherwise, the insurer will not pay any claims for a 12 month period, despite the thousands in premiums you paid just to be "included". Unbelievably, this is real, folks.


    Wendy,

    I'm afraid another missive is on its way to Ms. Ravenel, though it doesn't address the question of the overdue (or not) premium.

    ---


    Dear Ms. Rutledge Ravenel:

    You have been chosen to participate in a brief survey based upon your recent experience with our policy on pre-existing conditions. Please take a moment to answer these questions and return the survey to us.

    1. Which of the following statements do you most agree with (chose one):
    a) It is not fair for people with pre-existing conditions to expect healthy policy holders to pay for their care.
    b) Taking care of people with pre-existing conditions distracts providers from taking care of people who have better long-term prospects.
    c) People with pre-existing conditions should think long and hard about how they acquired them.

    2. True or False: I would rather have an insurance policy that does not provide comprehensive coverage than have one that I cannot afford.

    3. Write a one paragraph essay to explain why you agree with the following resolution. Resolved: The predisposition of women to acquire the pre-existing condition of menopause should be recognized as a pre-existing condition in and of itself, disqualifying them from coverage for any and all treatment of female problems from the time of birth.

    Your answers will be used to inform our policy on pre-existing conditions going forward. Please be assured that your identity will not be disclosed to anyone outside the corporate management of JSNHI.

    Sincerely,

    Sarah Sowrong, Ass't to the Director
    Customer Relations


    Dear Ms. SoWrong:

    I just received your survey and will respond to it later this morning after I return from a dental appointment that may require us to discuss the "pre-existing condition" of having teeth.

    Sincerely,

    Susan Rutledge Ravenel


    OMG! Teeth!

    Do you not know that failure to disclose a pre-existing condition is grounds for recission?

    Let's hope Ms. Sowrong isn't paying attention.


    Ms. SoWrong:
    In answer to your survey:
    1) none of the above;
    2) false,, but not for the reasons you offered;
    3) Essay:
    Why is it that JSNHI fails to answer a straightforward question, to wit: are you refusing to cover annual prostate exams for men who have had vasectomies?

    JSNHI's failure to answer this question implies that, either:

    a) the question is faulty; or,
    b) the question is germane to the disparity between cost and coverage for men, versus cost and coverage for women.

    I think the answer is B, which stands for JSNHI b*llsh*t. But that is just my opinion.

    Sincerely,

    Susan Rutledge Ravenel


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