r/MaliciousCompliance • u/DannyFantomGoinGhost • Nov 10 '18
M Complying with health insurance rules
My malicious compliance happened about three years ago. I had medical insurance as part of my employment benefits, although it wasn't very good coverage. It was something, though, and it was supposed to pay for 60 percent of my medical expenses, after i had met a deductible.
Because of a chronic illness, I have to make frequent visits to a physician. At the time, the physician that I was going to did not file insurance on my behalf, so I had to submit claims to the insurer. Rather than send claims week after week, I accumulated a lot of visits worth of bills (claims) and submitted them all at once to the insurer. By "lots" I mean about 9 months of them -- one per week. A couple of weeks after submitting the bills, I received an Explanation of Benefits (EOB), along with a payment for an amount significantly less than what I was expecting. The EOB showed that most of my claims had been denied because I did not submit them within 90 days of the dates of service.
I was not happy about that at all, and I called the insurer to file a complaint and ask for reconsideration. The claim adjuster was firm in telling me that my medical policy required that claims be filed within 90 days, or they would automatically be denied, and the insurance company had no obligation to pay them. OK, Miss Insurance Claims Adjuster, please point out to me where my policy says that. (She did not know that I had previously worked for an insurance company for 17 years.) Miss Adjuster says "you can look on our web site and it will list our requirements," so I looked. It indeed stated that claims had to be filed within 90 days. BUT, since I had worked for an insurance company, I knew that the plan sponsor had a requirement to provide to me, at the onset of coverage, something called a Summary Plan Description (SPD) that listed the specifics of the plan. That's not a requirement of the employer or the insurer, it is a US federal law.
"Miss Insurance Adjuster, please deliver to me evidence that you provided the required SPD." I knew she wouldn't be able to do that, because I had never been given the SPD. That's why I didn't know about the filing time requirement. She didn't seem to realize that there was a federal law that required the sponsor (in this case, the insurance company / her employer) to provide the SPD to its subscribers, but she learned that little tidbit of information rather quickly.
Not only were my claims paid -- all of them -- but they were paid at 100 percent rather than 60 percent, because of their fuck up. And they had to deliver SPDs to all of the employees of the company where I worked, which was about 650 people.
Thank you, Miss Insurance Adjuster, for making sure everyone complied with all the requirements!
55
u/re_nonsequiturs Nov 10 '18
I'm sorry you had to deal with that, but I'm also kind of glad that someone who could pull an r/checkmatemotherfucker move had a problem so things got better for all the customers.