Think you have maternity coverage? Think again.

Welcome to the first entry of the book I’ll be publishing in 2010 entitled: You gotta laugh: Life in the trenches of the health insurance business. Because I think Disruptive Women readers will find it useful, each month I’ll post an example of a health insurance problem that is so maddening and frustrating that we just gotta laugh at its absurdity.

My goal, however, is to find a way to improve health insurance for beneficiaries and I have some suggestions at the end of this post.

This month’s question: What do you do when you have it in writing from your insurance company that you have maternity coverage — but when you go to use the benefit, the customer service department tells you otherwise?

The situation: When our client, Ms. R, found out a few years ago that she was having a baby she was thrilled. Immediately, she called the insurance company to confirm her pregnancy benefits. Making the call was merely a formality. When she originally purchased the policy, she was single and didn’t opt for the maternity rider. After she got married, she added maternity coverage because she wanted a family.

Indeed, when she called the insurance company, they confirmed she had the insurance she needed. However, after her first OB check-up she received a letter saying she was, in fact, not covered.

Panic ensued, followed by a slightly hysterical call to my office. We quickly phoned the carrier, and unfortunately it took two weeks of repeated calls to get the information we needed. Finally, we received an email from a reliable supervisor confirming that the rider had been added and she was covered.

Three years later, Ms. R became pregnant again. Following proper protocol, she again called the insurance company to notify them of her second pregnancy. She was told she had no coverage. Surely this was a mistake. She hung up, composed herself, and called back.

This time another agent told her she had dropped her maternity coverage the day her first child was born. Frustrated and confused, Ms. R called me. Who would drop their coverage while giving birth? The only person who can drop coverage is the one who is insured. I don’t know about you, but I was not calling the insurance company during my 27 hours of labor.

Ms. R saved an email from the insurance company stating that she had coverage prior to getting pregnant the second time. Although the letter clearly stated that she had maternity coverage, it took three people making nine calls for four weeks to get a definitive answer ­— that Ms. R did in fact have coverage and the policy would pay for her delivery.

What we never did discover was why the coverage was dropped in the first place. Who authorized the change? And why did it take so long to resolve the matter? You gotta laugh.

Here’s how you can take control

What can you do to make sure a situation like this doesn’t happen to you?

1. When you are thinking about getting pregnant, call your broker or insurance carrier to confirm that you are covered.
2. Make sure to get the name and telephone number of the person you spoke with, the department and supervisor’s name and telephone number, and the reference number for the call.
3. Always write down the date and time that you placed the call.
4. When buying a policy, if you are of childbearing age, be certain that you are covered for maternity.
5. Get a copy of your contract and review it carefully to be sure you are covered for all future potential situations.

If I were the health insurance ambassador

If I were in charge of health insurance policy, I’d make sure that every carrier clearly outlined and explained what is covered in the policy. When amendments are made, policies should be updated, customers notified, and changes posted on the insurance company’s website using easy-to-understand language.

Too often, this information is buried in the policy and is difficult — if not impossible — for consumers to understand. I’d also make sure that carriers were required to respond to issues like Ms. R’s within 48 hours.

Related posts:

1. Life in the Trenches of the Health Insurance Business: Calculating Coverage for Adult Children
2. Life in the Trenches of the Health Insurance Business
3. News Flash to Health Reform Buddies: Insurance Coverage is Not Enough
4. An end to the health insurance advocate: Will insurance brokers survive health reform?
5. Top 8 Reasons Single People Don’t Buy Health Insurance — And why they might want to reconsider that decision

This entry was posted on Tuesday, December 29th, 2009 at 10:33 am and is filed under Access, Childbirth, Consumer Health Care, Coverage Policy, Insurance, Patients' Rights. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.