Part 1

Okay, I’m going to start off with a little background info. I work for a health insurance company doing customer service. I’m not saying which one, for my own sake. But, I’ve dealt directly with most of the big ones for group insurance, and they seem pretty similar. So the ground rules: I will be talking about group health insurance here, if you have insurance that is not provided by your employer, this will not necessarily pertain to you. This is also just my experience from working there (3 years) plus having to deal with them and learning about the insurance companies. So, here we go.

The most important rule to remember: The insurance company is not evil, they are stupid. Now, the person who you call and talk to may be very intelligent and know exactly what they’re talking about, however, the people who you don’t talk to (supervisors, other reps, claims, provider department, appeals) could be completely retarded, either in general, or just on that day. Now, there are several reasons for this. While the company itself is probably a money-grubbing whore, they do not actually benefit from processing your claims wrong. Your premium goes mostly into an account which has been set up by your employer and belongs to your employer. The insurance company is given access to it in order to pay the claims made by anyone in your company. A far piece of that does go to the insurance company for administering your plan. They pay the claims and take all the calls so your company doesn’t have to.

Second, the plan is written up by your employer. Why isn’t your gastric bypass covered, why can’t you get chiropractic or massage work under your insurance? Because your employer, your company, chose not to pay for that. Same with preventive care, elective abortions, contraception, mental health and so on. The insurance company doesn’t benefit from these things not being covered. In fact, in a lot of cases, if they were covered, the administration fee they get would be higher, so they actually like covering things. So, politics and viewpoints and such on what is or is not a valid medical treatment has very little to do with the actual plan itself. So starting with accusations of your insurance company not paying things to save themselves money is almost always wrong. They may be saving your employer money, but that’s not necessarily in their interest either. As incorrectly denying claims can cause them to lose that employer’s business.

Also, trying to bully the phone representative is a bad idea. Because insurance is confusing and sometimes very convoluted, they have a distinct advantage of having been specifically trained on how to interpret everything. They will certainly not get everything right, so don’t implicitly believe everything they say, but in most cases, they have a lot more information than you when it comes to the claim itself. In which case, harassing them or being overly aggressive not only makes them think faster and in a lot of cases makes them dislike you, causing a rise in anger, which will shut down both their ability to fully understand the situation and possibly figure out a solution for you AND will make them much less likely to want to help you. And don’t believe that “It’s their job, they have to help me”, because that line of logic will not benefit you. In a lot of cases, they have several ways to keep themselves from helping you and the ability to communicate with the other reps they work with and warn them that you are unreasonable making the other reps start with a negative view towards you. All these serve to work against you in helping to right your claim.

So to conclude part 1, try not to blame your insurance company if something is not covered on your plan. Take your grievances to your employer. Find other co-workers who agree with you and try to convince your employer to add this coverage to their plan. That is your best course of action. Negotiate with your employer as much as possible to have them realize what the priorities of the workers’ needs for that company. And if you believe that your insurance company has processed something wrong, by all means, call them, but try to start from a position that it may be correct and if the rep gives you any reason to believe that it is not, do not attack them. They, in most cases, honestly want to help you, that’s why they suffered through months of training. They want to help people, pleasant people make for easier days and less work. They will appreciate it if you are civil with them, even if the insurance did screw up your claim. These tips should benefit you in dealing with your insurance company.

P.S. Most importantly, take news stories and internet reports with a grain of salt if they don’t mention that they are referencing group or individual insurances. Individual insurance is quite possibly out to get you. Of this I have no doubt. Group insurance on the other hand, really does want to help you. They can only lose business by not helping you. But they do have to obey the rules given by your employer on your plan.