My Saga with the Insurance company.

When I was in London, I called Humana my supplemental Insurance company and alerted them about my health and how I had to pay up front the monies towards the treatment and hospital stay. The lady I talked to was very gracious and advised me that after I return home I should go to my Primary Care physician and have his office put in a claim. I would be reimbursed 80% of the total amount. Fair enough. But there are two sticky parts to this saga.

I called my doctor’s office and made an appointment. I took all the papers with me and talked with the nurse and the physician. Since I had retired, I hadn’t really acquired a regular physician. Just thought I didn’t need anyone, I suppose! Arrogant b****h!  But, about three years back I thought I would get someone, and the recommendation of one of my former patients I chose this young guy. The patient had said; ” Dr. Ali, he is really like you. He sits and talks to you, and looks at you while you are talking and he really reminds me of the way you took care of your patients.” So, I thought ok, I will do that. and established myself with his office.

He was okay and he was pleasant. I would see him once a year and that was more than what I wanted. So, after I retuned from London, I went to his office along with my son. {My kids didn’t leave my side the first month or two after I returned home for London. I think they thought that I was going to keel over and croak any minute!} The physician came and sat down and talked for about twenty minutes or so, enquiring about the event, and the hospital stay etc. He was surprised that the cost of my stay and the angiogram was only $8K. Any way he exchanged some more pleasantries and shook hands with us and left the office.
I was somewhat miffed. The guy  did not examine me. He never checked my heart, for rhythm or tone, my lungs to see if there was any fluid, and never examined my ankles to check for swelling etc. I left the office and told my son, wasn’t that strange that he didn’t examine me? Sayeed agreed.

Anyway, a couple of days later, I called his nurse and asked that she send me the office notes of my visit to the doctor. She said she would and she did. I received the entire report from this doctor, where he had outlined a complete and thorough examination, from head to toe, my peripheral pulses, and how my abdomen was not tender, and my lungs were clear and heat tones were good. My mouth had no abnormality etc. etc.

You get the gist.

I was livid. The guy had not so much as touched me, except to shake my hand when he was leaving the office, and here he was describing on paper, my body after the MI as if he had examined me thoroughly. I called the executive director of the Clinic and asked for an appointment with him. Meanwhile the clinic had already sent me a bill for his services for that day, and it had gone through to Humana Insurance company. They had deducted whatever and I had to pay the rest of the amount. Which I did.

I talked with the director and told him what had happened. I told him that my son was with me, and was disappointed that a physician would stoop so low as to lie about examining a patient, a physician no less, and send a statement to me and to the insurance company. I told him that I will not report to Medicare about the fraud, but told him that my family was considering doing just that. Needless to say, the man was perspiring and took care of the situation and I transferred my records to a wonderful physician through the hospital. Apparently the guy who was fraudulent was taken to task and God knows what else. But, he continues to work there.

Now for the second part of the problem.

I knew that I couldn’t ask his office to submit my claim to the Humana Insurance company. I called my own office manager who had worked for me, and asked her to help me. She did the whole thing for me and submitted the paper work on the 9th of September. I was told that I should be getting a about $7K.
I sat around and waited. By middle of October, my patience ran thin and I called Humana. I was told that the claim was being processed. On the 12th or 13th of November,  I received a check for $2900.  What?? I was so disappointed. Their booklet clearly stated that foreign travel reimbursements, if we had the right group of insurance would pay 80%. I called the Humana office and talked to a person. She reviewed the claim and said, ” Yeah I think there is a mistake. You should be getting close to $7K.” The amount I had paid through my credit card, was about $8.8K. She told me she would talk to the claims office and someone would get back to me. Meanwhile I was not to cash the check, which had a three month expiration date!

I called them in Mid December and I got a similar response, again. In early January, when I called again, the supervisor came to the phone and said that since Medicare didn’t cover the part of this claim, the Humana company would have to correct that, and so the amount paid to me was correct. She was blunt and sort of rude.

Finally in January I went to see my lawyer. He heard every thing, looked at the Humana booklet which very clearly says that the amount reimbursed will be 80% of the total amount the patient spends abroad for health services. He sent a “very nice” letter to the supervisor at Humana and asked her/him to clarify what the booklet meant.

We didn’t hear from them all of January. The deadline for the expiration of the check that they had sent was January 31st. The lawyer said to sit tight. Early in February he called the company while I was in his office and asked what the delay was about.

Guess what?

The person at the Kentucky end said, “Oh we are so sorry about this mistake. We have issued a check to Dr. Ali for $4,700, and she can cash this check along with the one we sent her earlier, giving her a total reimbursement of $7600. This all happened on the speaker phone and I sat there with my jaw on the ground.

I got that check two or three days later, and I cashed it. They paid me more than what was due! Whew!!

I really didn’t want to say much about this, but because Matt (Elusivewords) wondered about it, I thought I would tell it all.

And that is the rest of the story.

{{ I am not revising my post. I hope there are no typos. If there are, you put your own words and figure them out!}} heh heh.




About Zakiah

I write poetry and some fiction, have a book that was published in 2012. . . Stray Thoughts/Winged Words. I have four grandchildren, ages 16 and half to almost 16 months. I love the ocean, and grew up along the Indian Ocean in South India. I am a retired physician. Don't know much else to say. Thanks for reading. That has been my profile for so many years. My daughter Saadia a great poet and story teller, has two sons; the oldest grandson is now 21 years old, doing architectural engineering at Missouri S&T in Rolla MO. His younger brother is almost 16 and taking driving lessons seriously and is in High School. The other two grandsons, children of my son Sayeed, are 9 and 5. I have recently published another book titled Gulistan, A home of Flowers. It has stories and memories of my childhood and of a distant land which I still consider as my HOME., even though I have lived here in the US for more than fifty years. Hope to see you on my blog.
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10 Responses to My Saga with the Insurance company.

  1. slmret says:

    I’m sorry you had such a run-around with Humana, and with the primary care physician, but it pays to be persistent!

  2. Oh my goodness… what a saga! The insurance process seems to be so screwed up. And next time you drop by the hospital, just stare at the doctor and watch him sweat. Or better yet, just hit him with a rolling pin.

    I’m glad everything worked out even though there was so much trouble.

    p.s. is it true doctors always feel they don’t need doctors? 😉

  3. mrswrangler says:

    I am sorry that insurance is such a fight. We fought them on Wranglers wreck. They asked for receipts for work done on the truck six months prior to the wreck. Than they cut the check $6000 less than value. The partnership just finally paid the bank off what was left to cover on the loan.

  4. mrswrangler says:

    And on doctors my last trip to the doctor was very similar. I had a bad cold. Instead of examing me and try to figure anything out they wrote me a prescription. The prescription was for a sulfer drug which I am allergic to. I argued with them but they said doctors know what they are doing. This clinic is connected to the hospital. They have ran the other two doctor clinics out by saying they can’t doctor at the hospital. I had a wonderful doctor who retired 10 years early after this drama. The hospital in the other direction the same distance away has a very bad record. I am debating doctoring 40 miles away at a good small town hospital.

  5. kaylar says:

    Argh, re them but good on you and yours for your persistence! (plus, I really really appreciate you writing this all out. You’ve just furthered my insurance education, of which I have none, so far.) Medicine. What a great business. Gr.r.r.r….

  6. murisopsis says:

    WOW. I’m glad it all turned out right in the end but it shouldn’t take a lawyer to pry the money loose! As for the doctor who didn’t examine you/said he did – I hope he gets his comeuppance!

  7. That is crazy but I’m glad it all worked out.

  8. beowulf222 says:

    Wow! My experience with my insurance company was so much more pleasant.

  9. Wowza! Wild! :-/ Scary! 😮
    So glad it all turned out so well!
    HUGS!!! 🙂

  10. r_hsw says:

    oh my. that took such a long ordeal for you to get your rightful reimbursement from the insurance company. i’m glad it is all done and you received the right amount.

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