I am a self-employed California Licensed General Engineering Contractor. It has been a struggle to find any insurance we could afford, and still is. We have a plan from a company called National Better Living Association or NBLA. It costs us $303 per month, which is close to the maximum I can afford. I have many complaints about them, but for the purposes of this particular event, I feel it is important for me to note that at the time this took place, the underwriter for our policy was A.I.G.!
My spouse has a disability which requires that she take heavy pain medication at a moment’s notice, and therefore she is not easily employable, so I am the only source of income/insurance in our household. In June 2009, my spouse had to have knee surgery to repair a torn medial meniscus. After paying for our own x-rays and MRI to the tune of $2,400 because NBLA won’t pay for diagnostics ever, we then set out to find an orthopedic surgeon in our network that our GP felt was competent. Two-and-a-half weeks later, we found him, so his office attempted to get approval for the surgery, and NBLA told them that I had to get the approval from them personally.
When I called NBLA to ask how to get this done, they informed me that I needed to fill out some forms about the diagnosis and fax them back, and that in they would negotiate with the doctor’s office and get back to me within a week. When they called back, I was told they had negotiated a price of $6,500 for the surgery, and that my maximum allowable benefit for this surgery was $3,000, but that in order to collect on that benefit, I would have to pay up front and submit all receipts along with more forms to fill out. I was told that in order to get the surgery scheduled, I would need to drive to the nearest branch of NBLA’s bank (Bank of America) and deposit the $6,500 in either cash or cashiers check.
We live an hour drive one way from any bank, so in addition to the five days I had already missed work trying to get approval, I was gonna have to take another off to do this. I scraped up about $3,500 from our savings account, and moved it to checking which cleaned out our savings, and got the rest from a customer payment from my last job, which meant there would barely be enough money for me to pay the month’s bills. I went to my bank (Not B of A), got the cashier’s check with not much problem, and headed to B of A. I was told to get an “out of state deposit slip,” and given an account number for NBLA Member Services Account. Once there, I got the slip, filled it out, and went to the teller.
I had been told to have the teller fax a copy of the check and deposit receipt to NBLA after making the deposit, so I asked her to do this, and she seemed happy to do so, but then the fax wouldn’t go through. After several attempts, I went to my truck to call NBLA for another fax number, went back in, and she got the same result. After many attempts over the course of an hour, one of the other tellers told her she should be dialing “9” to get out — not exactly NBLA’s fault except that it is them requiring it — but very time consuming and annoying nonetheless. So then we have the surgery done two days later, it goes very well, and I feel as though I accomplished the moving of a mountain with a teaspoon to get to this point. Even though I will only be recovering a little less than half of what I paid, I figured it was better than nothing, right? Wrong!
When I picked up my spouse from the surgery center, the grumpy receptionist informed me, as though it was my fault, that NBLA had paid them and the surgeon, but had forgotten to include the anesthesiologist’s bill, and that I would be getting a bill from his office separately. I told her that figured, since the money NBLA used to pay them was my money anyway, and we went home. I then started to fill out the claim form which stated that I would need to submit itemized receipts in order to get reimbursed. So I called the surgery center and was told, “I’m sorry sir, but surgery centers don’t print itemized receipts like hospitals do. All I can give you is what you got when she checked out.” Somewhat worried, I reluctantly sent off the package, which had taken me yet another work day to fill out and organize.
Here comes the the kick in the face. Four months later, a check arrives from NBLA for $405 for reimbursement on the knee surgery. On the check stub, it reads “Maximum payout for this procedure has been met.” If that is not enough to make one’s blood boil, when our GP bills them $80 for an office visit, they pay her $10.14 for the first three visits per person per year and then nothing after that!
We need help for self employed people who are not able to get employer health insurance. The insurance industry is out of control and does whatever they want. I don’t see anything changing soon, but I hope this story will help to change something! Keep on fighting! Thanks to all who read this, and good health to you. Anything else is too expensive!