Erisa

[greasemonkey]

Employee Retirement Security Income Act of 1974

 

what a really cool plan; put in place to protect workers pensions. Around 1986 or so it ballooned out to provide all sorts of useful things relating to almost all employee benefits, including health benefits.

 

Back in 2003, I got a really good idea of what ERISA often does to help the good old common everyday Joe's like me! I had a problems with my sinuses; my ENT (ear nose & throat) doctor (among others) had told me on quite a few occasions that I would really benefit from surgery to fix my severly mis-shapen septum. After a couple of years (and the onset of my kind of odd disability), I decided that since I wasn't working anyway and had already met my deductible for the year, I might as well have the surgery.

 

Kind of odd how it all worked out; of all days to go in to schedule it, I did it on my birthday (in December). I sat there while my doctor's nurse called my insurance company to get approval. She spoke with a nice young lady named Tiffany who told her that no pre-approval was necessary for that procedure; we scheduled it for the next week, and all was cool.

 

Until a couple of months went by.

 

The hospital had made a small error in the billing (they listed me as in-patient surgery instead of out-patient), and the claim was denied. The hospital fixed the problem, and the insurance company paid off maybe a month or two later. The surgeons claim was also denied. And denied again, and again. Then they got their "medical expert" to look at the surgical record, and deemed the surgery as "exploratory." My doctor was FURIOUS with them ...even wrote a really nasty letter to their so called "expert," but never received a response (I ought to frame that letter, it was pretty funny).

 

...so I basicly got stuck with about 15K in surgeons fees. I can't even begin to count the number of phone calls and appeals I went through. I mean really ...if the surgery wasn't covered, why the hell did you pay the hospital but not the doctor who performed the surgery?! Every time, the people said it didn't seem right & promised to look into it (or did they promise to conveniently lose it?).

 

After over a year of this, I finally contacted an attorney about the whole silly business and got some really interesting news about ERISA. No attorney would touch my case, almost every single lawyer who practices ERISA law only works for the insurance companies. ERISA is pretty cool in it's "protections" that way. It pretty well says that you can't sue until you have exhausted every possible means of "arbitration" with the insurance company, and then when all of that runs out, all you can sue for is the amount of the surgery itself (ie: you have to pay all the legal fees yourself). Even better still, the insurance companies have the ability to tie it up in the courts for just about however long they want to; of course, the plaintiff can do that too, but who can afford it?!

 

So basicly, most any health insurance company can deny almost anything they want to because they have absolutely nothing to lose. The most you can sue for is the original amount. The ONLY thing holding them in check is that poor customer service means you don't get as many clients.

 

The sad irony of this story is that my doctor passed away in December. I played the "arbitration" game of theirs, and they did indeed finally pay for the surgery. Two weeks before the death of my doc; one year and eleven months after the surgery (and miraculously, eight months after I had cancelled my coverage with them).

 

Now, just for the sake of derailing the original topic a bit. I recently read that Supreme Court Justices Thomas and Scalia were the only two justices who voted in favor of a law that would have allowed employers to make employees sign a requisite agreement that stated that they wouldn't sue for discrimination until it had first passed through an employer chosen "arbitration board." This was well before our two new "conservative" justices jumped on the ship; but it really makes me wonder how anyone could really support these "compassionate conservative" justices.

 

Well, as long as they are pro-lifers, I guess they must be all right kinda guys!

[BlueGiant]

Out of curiosity, would you mind naming the insurance company so I know when I should change my coverage?

[Fweethawt]

Heh!

Kinda like my situation.

Sure, I have a job.

Sure I got me some medical benefits.

Do I have problems that need looked into?

Yep.

Can I afford to use my "benefits"?

Nope.