6:55 p.m. - 2006-01-24
rant about insurance
Tuesday, January 24, 2006
I have a rant coming on. It started in my office about an hour ago and I just can't get it out of my head.
I work for an insurance agency. I used to be an insurance claims adjuster for a company for 25 years. I learned from the ground up how to handle claims and how to read policies. In some states, some of the policy language has to be the same. Accordingly, in some policies, the language is not the same. No matter which way the policy is written, you have to abide by the language. Therefore, you have to be able to read the policy, interpret the language and apply the coverages.
As an adjuster, you also need to be able to use logic. You have to investigate the claim, get all the facts and learn to use your head. Your main goal is to pay what is owed as quickly as possible. I was taught to be honest, sincere and to treat the policyholder as my only customer. In other words, abide by the Golden Rule and treat them as I would expect to be treated.
You might say you would try to bend over backwards to help.
. These days I have noticed more and more that insurance companies are hiring young people and they are not trained to work as I was. They are put in a cubicle, given one type of claim to handle and they have no idea how to work outside of their box.
Most of these adjusters have a college education but they have no "street smarts", they have no investigative skills and they can't put the facts together.
I turned in a claim for a policyholder who was injured while driving her car. The other driver's insurance had already paid for the damaged vehicle. Our policyholder was having on-going physical therapy. She was paying for it out of her pocket. She told me that her doctor was going to re-evaluate her condition and possibly send her to a different therapist to try to give her as much recovery as possible. I told her I would turn in the medical claim on her auto policy as she had $5000 coverage for medical. My intention was for the insurance adjuster to pay her back the $2500 she had already paid out of her pocket. If she did have more medical bills, then she would still have coverage for up to another $2500. Also, I provided the insurance adjuster with the name, phone number, claim number and so on for the other driver's insurance company. (in other words, I had all the information but I couldn't do the claim work because I am not an adjuster any longer but I was giving the adjuster everything he needed to handle the claim.)
First, the adjuster did not pay her back for her out of pocket expenses but she was fine with that. She knew she would be having a settlement with the other company anyway and she could get that money back. Besides, this provided her with $5000 coverage if she needed that much more medical treatment.
Whenever a medical facility calls for authorization to treat a patient, they must talk to the adjuster. I always provide the name, phone number, claim number to the medical facility and advise them to contact the adjuster.
This customer had additional physical therapy for about 4 months. She called when she was released. I discussed with her how to negotiate with the other insurance company. I also told her to make sure her own adjuster knew when she was having the negotiation meeting for settlement. I, personally, also called the adjuster at least 3 times leaving voice mail messages to be sure he filed for the amount that his company had paid out for this policyholder. He did call me once and we talked about the claim.
When the policyholder was ready for her settlement meeting, I had already discussed the amount that the insurance company had paid out, the amount that she had paid out and what she should ask for in a settlement and how to figure out what she wanted for "pain and suffering." I also told her that her husband was entitled to a settlement because she was not able to "perform her wifely duties" and also he did more of the housework and so on. I also reminded her to write down all the activities she could no longer do such as horseback riding, gardening, water sports, etc.
She reached a settlement figure in late November. The check was made out to her and her husband for the "pain and suffering". Another check was made out to her and to her insurance company to repay the medical the insurance company had paid out. This is called subrogation.
She brought in the check payable to her and the insurance company to me at my agency. I personally mailed the check with a cover letter to the insurance company. The claim was closed in December, 2005.
Ok, GET READY, HERE IT COMES!
Last week, I got a phone call from the physical therapy facility. It seems that the insurance paid some of the bills but not all of them. They called the insurance company and the adjuster said they would not pay the bills because the policyholder had signed a release and settled with the other insurance.
I told the medical facility to fax me whatever they had to prove they filed the bills in a timely manner. In other words, did they bill the insurance company BEFORE the settlement? I got about 4 pages showing the computer readout that the bills were filed monthly direct to the insurance company,
I called the adjuster and asked him to check on when he received these bills.
He, of course, told me the bills wouldn't be paid because of the settlement. I TOLD HIM if he had the bills prior to the settlement and he didn't get them paid, that was his fault not the medical provider's or the policyholder. He agreed to get the claim file back and check it out.
Today I got a call from medical provider again. The adjuster called her and said the physical therapy treatment was not related to the accident.
So here is my plan for tomorrow. I am going to call the medical provider and ask if they have a referral note or the policyholder's history from her doctor. If so, I will ask them to fax it to me. I would assume it will state that the doctor wanted her to have more physical therapy. Then I am going to ask who called the insurance company for authorization and did they speak to the adjuster.? This will clarify the treatment was related to the accident and even more that authorization was received from the adjuster.
I am then going to call the adjuster and ask him if he took a recorded statement from the policyholder and did she tell him her doctor wanted to refer her for more physical therapy? I am going to ask if he gave authorization to the medical facility. I am going to ask where the old unpaid medical invoices have been and when was he advised that the treatments were not related to the accident (if they were). Then I am going to ask him if the treatments were not authorized, why were some of the medical bills paid to the facility? Also, if the treatments were not authorized, why didn't he advise the policyholder so she could have turned them into the other insurance company when she was in a settlement negotiations? You see, if the insurance adjuster doesn't pay the bills, the policyholder will have to pay the medical facility.
My educated guess is that the bills were put in the claim file and overlooked. Now, since the settlement is completed and the adjuster knows the medical bills won't be repaid to the insurance company; he is trying to find a way to deny coverage so he won't be in the wrong.
This has been another in a series of mistakes and sloppy adjusting that this particular company has been guilty of for about 2 to 3 months. My boss and I are planning to present this information to our field representative later next month. It is disturbing because we have to fight with the company we write policies for... It makes me wonder how they treat their customers.
Last summer, they were charging customers a $300 deductible if they had to use the Uninsured Motorists coverage because the vehicle that damaged their vehicle had no insurance. We argued about that and pointed out that there was nothing in the policy stating there was a $300 deductible. They told us we were wrong. Late last year, a letter went out to all Indiana policyholders advising that if they had an Uninsured Motorist claim and were charged the $300 deductible to contact the insurance company "because there was a mistake!!!
Ok, I am done now.
Here's some jokes to lighten up the evening.
George Carlin's Views on Aging
Do you realize that the only time in our lives when we like to get old is when we're kids? If you're less than 10 years old, you're so excited about aging that you think in fractions.
"How old are you?" "I'm four and a half!" You're never thirty-six and a half. You're four and a half, going on five! That's the key.
You get into your teens, now they can't hold you back. You jump to the next number, or even a few ahead.
"How old are you?" "I'm gonna be 16!" You could be 13, but hey, you're gonna > be 16! And then the greatest day of your life . . . you become 21.
Even the words sound like a ceremony . . YOU BECOME 21. YESSSS!!!
But then you turn 30. Oooohh, what happened there? Makes you sound like bad milk! He TURNED; we had to throw him out. There's no fun now, you're just a
sour-dumpling. What's wrong? What's changed?
You BECOME 21, you TURN 30, then you're PUSHING 40. Whoa! Put on the brakes, it's all slipping away. Before you know it, you REACH 50 and your dreams are gone.
But wait!!! You MAKE it to 60. You didn't think you would!
So you BECOME 21, TURN 30, PUSH 40, REACH 50 and MAKE it to 60.
You've built up so much speed that you HIT 70! After that it's a day-by-day thing; you HIT Wednesday!
You get into your 80s and every day is a complete cycle; you HIT lunch; you TURN 4:30; you REACH bedtime. And it doesn't end there. Into the 90s,
you start going backwards; "I Was JUST 92."
Then a strange thing happens. If you make it over 100, you become a little kid again. "I'm 100 and a half!"
May you all make it to a healthy 100 and a half!!
HOW TO STAY YOUNG
1. Throw out nonessential numbers. This includes age, weight and height. Let the doctors worry about them. That is why you pay "them "
2. Keep only cheerful friends. The grouches pull you down.
3. Keep learning. Learn more about the computer, crafts, gardening, whatever. Never let the brain idle. "An idle mind is the devil's workshop." And the devil's name is Alzheimer's.
4. Enjoy the simple things.
5. Laugh often, long and loud. Laugh until you gasp for breath.
6. The tears happen. Endure, grieve, and move on. The only person, who is with us our entire life, is ourselves. Be ALIVE while you are alive.
7. Surround yourself with what you love, whether it's family, pets,keepsakes, music, plants, hobbies, whatever. Your home is your refuge.
8. Cherish your health: If it is good, preserve it. If it is
unstable,improve it. If it is beyond what you can improve, get help.
9. Don't take guilt trips. Take a trip to the mall, even to the next county; to a foreign country but NOT to where the guilt is.
10.Tell the people you love that you love them, at every opportunity.
AND ALWAYS REMEMBER:
Life is not measured by the number of breaths we take, but by the moments that take our breath away.
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~ TIBETAN PERSONALITY TEST ~
>
Take your time with this test and you will be amazed.
The Dalai Lama suggests you read it to see if it works for you.
Just 4 questions and the answers will surprise you.
Be honest and do not cheat by looking up the answers. The mind is like a parachute, it works best when it is opened. This is fun to do, but you have to follow the instructions very closely. Do not cheat.
MAKE A WISH BEFORE BEGINNING THE TEST
A warning! Answer the questions as you go along. There are only 4 questions and if you see them all before finishing, you will not have honest results. Go down slowly, and complete each exercise as you scroll down. Don't look ahead. Get pencil and paper to write your answers as you go along.
You will need it at the end. This is an honest questionnaire, which will tell you a lot about your true self. Give an answer for each item. The first thing that comes to mind is usually your best answer. Remember - no one sees this but you.
>(1) Put the following 5 animals in the order of your preference:
Cow, Tiger, Sheep, Horse, Pig
(2) Write one word that describes each one of the following: Dog, Cat, Rat, Coffee, Sea.
(3) Think of someone, who also knows you and is important to you, which you can relate them to the following colors. Do not repeat your answer twice. Name just one person for each color:
Yellow, Orange, Red, White, Green.
(4) Finally, write down your favorite number, and your favorite day of the week.
FINISHED? Please be sure that your answers are what you REALLY WANT.
But first before continuing, REPEAT your wish.
THE ANSWERS WILL BE AT THE END OF THIS JOURNAL
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Headlines from the year 2034
Ozone created by electric cars now killing millions in the 7th largest country in the world, Mexifornia formally known as California. White minorities still trying to have English recognized as Mexifornia's third language.
Spotted Owl plague threatens northwestern United States crops and livestock.
Baby conceived naturally . Scientists stumped.
Couple petitions court to reinstate heterosexual marriage.
Last remaining Fundamentalist Muslim dies in Bushra; the American Territory of the Middle East (formerly known as Iraq, Afghanistan, Syria and Lebanon).
Iran still closed off; physicists estimate it will take at least 10 more years before radioactivity decreases to safe levels.
France pleads for global help after being taken over by Jamaica.
Castro finally dies at age 115; Cuban cigars can now be imported legally, but President Chelsea Clinton has banned all smoking.
George Z. Bush says he will run for President in 2036.
Postal Service raises price of first class stamp to $17.89 and reduces mail delivery to Wednesdays only.
Average weight of Americans drops to 250 lbs.
Japanese scientists have created a camera with such a fast shutter speed, they now can photograph a woman with her mouth shut.
Massachusetts executes last remaining conservative.
Supreme Court rules punishment of criminals violates their civil rights.
Average height of NBA players now nine feet, seven inches.
New federal law requires that all nail clippers, screwdrivers, fly swatters and rolled-up newspapers must be registered by January 2036.
Congress authorizes direct deposit of formerly illegal political contributions to campaign accounts.
Capitol Hill intern indicted for refusing to have sex with congressman.
IRS sets lowest tax rate at 75 percent.
Florida voters still having trouble with voting machines.
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ANSWERS:
(1) This will define your priorities in your life.
Cow Signifies CAREER
Tiger Signifies PRIDE
Sheep Signifies LOVE
Horse Signifies FAMILY
Pig Signifies MONEY
(2) Your description of dog implies your own personality.
Your description of cat implies the personality of your partner.
Your description of rat implies the personality of your enemies.
Your description of coffee is how you interpret sex.
Your description of the sea implies your own life.
(3) Yellow: Someone you will never forget
Orange: Someone you consider your true friend
Red: Someone that you really love
White: Your twin soul
Green: Someone that you will remember for the rest of your life
4) You have to send this message to as many persons as your favorite number and your wish will come true on the day that you recorded.
This is what the Dalai Lama has said about the Millennium - just take a few seconds to look it up, read it and think.
Do not put away this message, the mantra will come out from your hands in the next 96 hours. You will have a very pleasant surprise.
This is true, even if you are not superstitious.
