Is ins co liable for extra costs if I pay?

[mmarsh]

Does anyone know what happens if I pay out of pocket for ADR and something goes wrong? Is the ins co mandated to pay for say a post-op infection? What risk am I putting myself in by paying?

M-

[Maria]

I'm guessing you're talking about your regular medical insurance that may have denied this surgery or just doesn't pay for it no matter where you go?

I actually hadn't thought about that altho it's surely a valid consideration.
Looking forward to seeing what replies you get, esp. from anyone who has had complications and how that was addressed re coverage with insurance.

[mmglobal]

I have not seen coverage for aftercare or complications denied after overseas ADR, but I do know patients who's insurance companies have threatened that they would not cover complications related to unapproved surgery.

It's all going to be based on your contract and how aggressive your insurance company is. (They seem to grow bolder and bolder by the day.) Seeking coverage in advance with an insurance company that will not pay may be a double edged sword.... Unless your contract precludes you from self paying for appropriate care... you should be in good shape. If you seek pre-approval and they come back with strong warnings against... you may have given them a leg to stand on if they wish to deny coverage for aftercare.

Good luck... let us know how it goes...

Mark

[dshobbies]

I know of one instance where the insurance company specifically pre-denied complication coverage for this uncovered procedure. Other than that, they might try to deny coverage like Mark stated, but then again, they are also succumbing to public pressure so who knows.

If you inform them in advance that you're going ahead with an uncovered procedure, you also give them the opportunity to pre-deny coverage so keep your intentions to yourself.

[mmarsh]

Spoke to my ins broker and she said the company is NOT liable for complications of an "unauthorized" procedure. I couldn't find this in my policy book so I'm glad I asked. It's a big risk if something bad happens...

Missy

[ans]

Hmm. So if you pay for an ADR state-side, your insurance can deny post-surgery care e.g. doc's visits, PT, etc.

[Maria]

Moving to another country with national healthcare coverage! I swear, why have insurance if we cannot even use it for an emergent cause even after we pay for something out of pocket! That's ridiculous. What about a facial infection after a facelift?? Not covered?

I paid out of pocket for laser eye surgery and I was seen in the ER to rule out an emergent eye condition, then sent to a specialist for an emergency consultation and it was all covered by my insurance.. I did make a call to the Triage center and speak with a nurse who directed me to the ER so I had followed insurance protocol tho believe me I had already decided to hit the ER and was just doing it as matter of protocol, nothing more..

It sucks that there is a group of non medical personnel making decisions as to what is going to be covered upon review and what isn't and so forth.. some of the reasonings I've seen in review have been ridiculous and totally incorrect from a medical standpoint (talking about UR decisions here which is Utilization Review used in Work Comp cases now and HMOs/Managed Care). And don't even get me started about underwriting because if you ever ask to see the underwriting for the policy you are thinking about taking out or have taken out, there are so many things that aren't covered that I'm surprised ANYTHING is anymore!!!

Ok, sorry about my rant but hey, it's not right. Might as well not have insurance if we cannot use it when needed esp. if there is a monthly payment going out from somebody's pocket and these premiums are pretty steep these days~

[dshobbies]

To continue Maria's rant, yesterday's news revealed that level 4 medications, used to treat cancer and ms, etc. are now being covered by some insurers no longer as a co-pay, but on a percentage basis, costing the insured as much as thousands of dollars per month. Why bother with insurance?

On another note, if something is not specifically mentioned in a policy as not being covered, then it should be. I'm not any kind of legal expert but a previously non-disclosed exclusion should mean inclusion and though it may come down to a legal fight, the written word usually has the last one.

If you're overly concerned, you may want to consult an attorney.

I had a 3 level with Dr. more than 2 years ago and since then, all my pm charges and meds have been covered as well as x-rays and post-op consultations and physical therapy. I do have a ppo which may differ from an hmo.

[mmarsh]

I have a PPO! I was and was not surprised by the information. It's seems as though these days they deny until you're dead or just go away. Unfortunately the state (CA) office of ins is no help either as to date they have never overturned an ins co regarding ADR. I found 2 docs who dissented in almost 80 cases. Made my head spin! What use is the FDA if not to guide consumers and ins cos as to what is available! It seems that as cos become more and more cost concious, RE meds and procedures, we are in serious trouble! It's not like ins coverage is cheap, either!

OK, there's my rant!

Missy

[Maria]

You would think I was overinsured by the sound of it but it's amazing just what isn't covered..

[nomorepain]

After a major spine surgery like ADR it's amazing to find out just what is covered and what is not! My ADR surgery was approved by my PPO, and i called in to find out what i might expect to pay, i was told before surgery it would be my deductable of $2,800 + $1,000 period! i thought! it was not explained that in a procedure like this there are many procedures and doctors and corporations not on the PPO list, like i had a choice , i was under general anastisia(my spelling is wrong), there were 3 surgeons, a vascular, not covered by my PPO, and a third in case my ortho or the vascular couldn't finish, he wasn't in the PPo list either, and they are not there free, all the little incidentals, like a CT scan after surgery, wasn't pre-approved& cost a bundle(but i was not told this prior) my out of pocket was just over $50K

[sahuaro]

nomorepain:
You certainly had quite an out-of-pocket expense for something that was "covered." I think your experience provides really important information for those considering surgery in terms of asking very specific questions about who
all the surgeons will be, what additional charges will be involved, and radiological studies post-surgery.

[ans]

Important topic - thanks. I spoke to Maya at Dr. Regan's office a few days ago. Only two insurance companies will pay so it'll be a Laurie Todd research/fighting game therefore.

[dshobbies]

Though I ended up in Germany, both Dr. R and D told me that neither accepted the limits of insurance and I would be expected to pay the difference. Until now I assumed all other doctors would be covered. Stupid me!

[ans]

D: You did the right thing and I hope your huge surgery was successful.

ans