I often wonder if anyone is reading what I write in this blog, but when I write about insurance companies I’m pretty sure someone will see it.  Thankfully, someone at Golden Rule Insurance did see what I wrote yesterday and called me to say that the problem “Alonzo”, a Golden Rule client, was having was all a mistake, or a mis-communication.  His policy does not have a six-month waiting period for any treatments or conditions because it is a HIPAA policy. And cancer treatment is never excluded or delayed.

Yesterday I wrote about “Alonzo” (not his real name) who got a health insurance policy from Golden Rule Insurance through HIPAA (the Health Insurance Portability and Accountability Act of 1996). This federal law allows people like Alonzo to get insurance even if they have pre-existing conditions -  if they have had group insurance which they have lost, and have no other option for health insurance.  The law was designed to prevent people from becoming uninsured when they lose group coverage – as long as they can afford the outrageously high premiums that come with HIPAA policies.

When Alonzo’s cancer doctor’s office called Golden Rule to check on his insurance coverage, they were told Alonzo’s policy would not cover treatment for his prostate for six months. Alonzo was shocked and dismayed (as was I). But as it turns out, the Golden Rule representative gave the doctor’s office incorrect information.  According to the Golden Rule public relations person who called me, there must have been some misunderstanding.  Perhaps the Golden Rule representative who talked to the doctor’s office staff did not understand that Alonzo had a HIPAA policy, which meant there would be no six-month waiting period for any and all treatments.  As well, the Golden Rule representative may not have understood that Alonzo’s treatment was for cancer.  Apparently, there is never a waiting period for cancer treatment.

The Golden Rule public relations person who called me was very nice and very sorry that Alonzo had had a negative experience with Golden Rule. She said the company was experiencing very high call volume from clients, and that might explain the long wait to talk to someone. And perhaps this also led to and a mis-communication about Alonzo’s policy.

As I am in the insurance business I can appreciate the Golden Rule explanation – if I give them the benefit of doubt.  Health insurance is very complicated.  There are dozens of health insurance companies and hundreds of different policies.  Doctors’ office staff spend a lot of time figuring out if their service will be covered, how much they will get paid, and what prior-authorization is required – details that are  different with each insurance policy.

Figuring out how your health insurance works can be daunting.  Not having insurance can be devastating.  I told Alonzo I was exhausted after spending the day trying to figure out how to get help for him and worrying about whether or not he would get the cancer treatment he needed.  Now imagine how Alonzo felt!

Yesterday I had a conference call with “Alonzo”, who is from Tucson, and Golden Rule Insurance. I waited more than ten minutes to talk to a Golden Rule representative. Then I got Alonzo on the phone. We  talked for five minutes and explained Alonzo’s situation. We asked to talk to someone who understood the type of policy Alonzo had. We waited another ten minutes to be transferred to someone who could, hopefully, explain exclusions in his health insurance policy.  We talked for maybe three minutes with a representative who had Alonzo’s information on her computer screen. We gave her information, asked her several questions, and then we got cut off.  Alonzo waited for a phone call from this Golden Rule representative, but the phone call never came.

How can a billion dollar company not follow-up on a dropped call from a client who has already paid them over $4,000 in premiums?  Alonzo’s story is complicated and frustrating.

Alonzo works for a small construction company that dropped its group health insurance because the premiums got too expensive, despite rising deductibles and co-pays each year.  Alonzo figures he paid over $80,000 in health insurance premiums over 20 years and he was never really sick all that time.  He is overweight and pre-diabetic, and at 64 he was about to be uninsured.  To make things worse, Alonzo was diagnosed with prostate cancer just as he was losing his group insurance.

Alonzo applied for coverage with Blue Cross Blue Shield and was rejected because of his pre-existing conditions (and this was before he knew about the prostate cancer).  His only choice for coverage was to use the Health Insurance Portability and Accountability Act (HIPAA) which is a federal law from 1996 that requires insurance companies to offer a health insurance policy to people who have had group insurance, but lost it.  People who would not qualify for individual health insurance due to pre-existing conditions can get a guaranteed issue health insurance policy under HIPAA.

The HIPAA law has several requirements, all of which Alonzo met.  The HIPAA law also lets insurance companies take their premium rate for a healthy person, add ten percent to it, and triple that number.  So Alonzo would pay over $1,400 per month for the Golden Rule policy which has a $3,500 deductible.  He chose to pay this premium to protect his family from financial ruin that can come with serious illness and no health insurance.

Alonzo arranged for treatment of his prostate cancer, and the oncology center contacted his insurance company to check on his coverage.  Golden Rule said Alonzo is covered, but there is a six-month exclusion for treatment of “reproductive organs”, and the prostate falls under this exclusion.

Alonzo called me and I did some research about HIPAA policies, but I think we need an expert’s help on this.  Does the HIPAA law allow insurance companies to charge ridiculously high premiums for people with pre-existing conditions and then offer a policy that excludes treatment for those pre-existing conditions?

Alonzo doesn’t have time to wait for answers.  And he may have missed his one chance to get decent (though expensive) coverage under the HIPAA law by choosing the Golden Rule plan. This is an example of why I hate individual health insurance and why I concentrate on Medicare.

UPDATE Thursday, January 6, 2011:  Golden Rule did call! And it turns out the problem was all a mistake, or mis-communication……and Alonzo has no exclusions in his policy.  See my Jan. 6th post for more details.