Insurance companies

Insurance companies usually feel like a complex web that you are just not supposed to find your way through.  Up to this point, you might not have had to rely on your insurance company for anything out of the unusual.  And now you may be faced with large medical bills, or you might be anticipating what type of bills are in your future.  In any case, it usually feels over-whelming.  Your first step is to find out what your exact coverage is.  Typically, you can contact your employer’s human resource department and ask them for a copy of the policy.  The next step is to attempt to read the policy, which in many cases is like reading Latin.  It might help to make an outline or a grid or highlight the important parts of your policy. 

 After you have tried, and have hopefully been somewhat successful in reading your insurance policy, you should call a representative from the insurance company to discuss any of your questions.  Often if you are informed about how your insurance policy works, you will be much more successful at making decisions and avoiding some unnecessary expenses.  Unfortunately, all of this can be confusing, but hang in there and ask a lot of questions.  And if you find a representative that is very informed, make sure you get their name, so you call them back when you have more questions.  A little tip, is when you do find a representative that is helpful; send a thank you note, along with a picture of your child to the representative and their supervisor, being on a personal level helps you in the future. 

Remember that you have a contract with your insurance company. You are the beneficiary and you have to prove that the request you are making is covered in the contract.  And the insurance provider has to prove that the request is not covered in order to deny a claim   Get everything in writing!

What are some of the issues to be aware of when using your insurance policy?

  • Spending caps.     There are different caps for different services. For example, you might have a million dollar cap on medical procedures per individual and a $1000 cap on medical equipment. There are also yearly and lifetime caps. Be aware of caps and spend the money wisely.

  • Deductibles.     Be aware of how your deductibles work. For example, one insurance policy might limit you to spending $1000 per year on equipment, and you know that your child needs two $1000 equipment items. If possible, it might be best to prioritize and purchase one piece of equipment this year, and purchase the other piece the following year. Or another insurance policy might have a $500 deductible per year on equipment. In this case, you would want to purchase both pieces of equipment in the same year, so that you only pay the deductible once.

  • Your physician does not know your insurance policy.     This includes physicians that are part of an HMO. They do not always know your exact coverage. There are different insurance policies within HMOs. So, when your physician makes any referrals, make sure it is covered under your insurance policy.

  • How is your child referred to a specialist?     Some insurance companies require your child to see their primary care physician before they are allowed to see a specialist. The primary care physician then makes a referral to a specific specialist. However, you should still make sure that specialist is covered under your insurance plan. 

  • How does your child receive a piece of durable medical equipment?     Very often, you must have a prescription from your physician for a piece of equipment and the equipment must be purchase from a specific vendor. Contact your insurance company before making the purchase.

  • Therapy Limits.     Most insurance policies place different limits on therapies. Be aware of your plan’s limits, so that you can use the therapy benefits wisely.  For example, some insurance policies allow three months of consecutive therapy per diagnosis. In this case, you would not want to start your child in therapy for a specific problem if you know you are going miss a lot of the therapy sessions due to vacation, surgery, etc. Because this stipulation will not allow your child to "make-up" missed therapy sessions.  Some insurance policies allow 30 sessions per year. In this scenario, you will want to space out the therapy sessions throughout the year and ask the therapist for home programs, so that you can carry out the program at home.  Some insurance plans will allow for an extension of therapy with written documentation of progress from the therapist.