Insurance Agent Forum

[schealthagent]

All of this talk about how bad GR is or isnt got me looking at their e & l and i noticed that there don't seem to be any exclusions on treatment of the foot. I called broker services and they said it all depends on what is deemed medically necessary and wouldn't give any details. Any of you guys who have been through lots of claims have any experiences to share on who treats foot problems what way? THanks.

[jbage007]

you are beginning to understand the way home office at g/r thinks, irrespective of its new ownership.

You're on the right track, my friend.

(good luck proving that foot care is in any way medically necessary)

Now here's another fun one. check the rather lengthy list of states where g/r does not offer coverage. they're licensed just about everywhere, but they do not offer coverage in many states where other major players do offer coverage (omitting the obvious of nj, ma, etc.). ever wonder about that? you may not have reason to with your marketing, but it just so happens that it became an issue in mine (I do business in about 40 states)

Hint: do you think they really "voluntarily" withdrew from those states?

[somarco]

So when did GR fire you?

[schealthagent]

[quote=jbage007;62960]you are beginning to understand the way home office at g/r thinks, irrespective of its new ownership.

You're on the right track, my friend.

(good luck proving that foot care is in any way medically necessary)

Ok, but has anyone had any claims experience to share as to how something would work out. For instance, what if someone had a recurring case of "Turf Toe" this is an injury not something that was pre existing but can require various treatments including orthotics. Anyone have any specific experiences? Even with other conditions - this is important information.

[somarco]

Carriers adjudicate claims according to contract. If the claim is a covered expense, it is paid (or discounted).

There are well over 10,000 CPT codes. There is no way, in this forum, or this life, to address all the "what if's" of a claim.

And there are plenty of foot injuries and illnesses that would be a covered item in almost any carrier's policy (assuming it is not a revealed and excluded pre-ex condition).

Some are localized while others may be related to other conditions such as neuropathy.

If you think a claim should be paid, and the carrier is not honoring the claim, then compare the EOB with the contract and either accept that the carrier is right or fight it.

In more than 30 years assisting clients with all the major carriers, I have had very few claims that were paid incorrectly. The few that were challenged were eventually resolved once more information was forthcoming.

[schealthagent]

I understand that it would take for ever to go through all the what ifs. But was just looking for any advise. The reason I asked you guys is that none of the carriers will help. I started studying the Humana E&L and it flat out says
That "foot care services" are not covered. I am waiting to hear back from the area sales manager.

Assurant: "Routine hearing care, routine vision care, vision therapy, surery to correct vision, routine foot care or foot orthotics."

Similar language with BCBS.

Anyway, so what has Golden Rule not paid to make you hate them so much?

[somarco]

I don't hate them. Use them quite a bit.

If you get hung up on exclusions & limitations (and all the other nuances) you will never sell anything.

More claims are denied (or reduced) for undisclosed PX and OON charges than anything.

[schealthagent]

Somarco,

I was asking JBAGE007 why he hates 'em so much. It is hard not to get hung up when someone asks you point blank. What do you tell them?

[somarco]

I pre-screen everything that is questionable. If someone specifically asks about turf toe (to use your example) I do a pre-screen with the underwriter.

Assurant: "Routine hearing care, routine vision care, vision therapy, surery to correct vision, routine foot care or foot orthotics."

Similar language with BCBS.

I don't know of any carrier that covers ROUTINE care. Medical care following an injury or illness is different.

[jbage007]

Originally Posted by schealthagent

I was asking JBAGE007 why he hates 'em so much. It is hard not to get hung up when someone asks you point blank. What do you tell them?

Here is just one teenie weenie example. You will have to note that this is not something "in the policy" so to speak. I have hinted to you folks that you have to look beyond the wording of a contract to try and get a glimpse into the soul of the company.

Part of the problems, a big part really, with Golden Rule was that it was a mickey mouse company for many, many years. It was family owned forever, and well, that's never a good sign, generally speaking.

Any of you who care to do so can verify this fact: Golden Rule has in fact pulled out of several states.

As you know, companies are not allowed to cancel individual contracts--they can only cancel one family if they withdraw from a state (I'm oversimplifying for the sake of certain posters on this board).

One of my clients in Louisiana is someone who was personally impacted by Golden Rule's departure from that state. His wife had just developed breast cancer, while being insured with Golden Rule. Within months of the original diagnosis, these folks were shocked and dismayed to find that their individual insurance was being canceled--because their company was pulling out of the state. (Why were they withdrawing, you might ask? Hint: It was not exactly voluntary, and Louisiana is not exactly the friendliest state for litigation, if you catch my drift.)

Now tell me, what are the chances that the wife of a self employed person is going to be able to get any kind of insurance coverage after being diagnosed with breast cancer and while just beginning treatment?


Withdrawing from a state is not something a legitimate company does on a routine basis. Company "X" (which shall remain nameless) has NEVER withdrawn from a state. Couldn't they do it tomorrow? Certainly. But this is where you have to look into the soul of a company and see what those people are really like who run that company.

This is only one of countless horror stories I could recant about the good ole' boys in Indianapolis.

Anyone ever heard of Medical Savings Ins. Co.? Ha. Now that's a good one. No, it's not exactly the "same" company as Golden Rule. But check out that company's history--see what happened to it after a certain Mr. Rooney took it over. Pathetic. Useless excuse of an insurance company.

Granted, it's a new day at Golden Rule. But the problem is the same people remain in prominent positions at that company, with some exceptions of course. Over time, the company may actually become a legitimate player. But for now, it's not worth the risk in my book.

MY REPUTATION IS TOO IMPORTANT TO STAKE IT ON A BUNCH OF NO-GOODERS WHO HAVE PROVEN THEIR PROPENSITY TO ACT IN THE MOST UNPROFESSIONAL MANNER.

Back to the foot thing. Toe turf is an "accident." Just like a broken ankle in that regard. Not routine foot care, which virtually no company is going to cover--and some will put it out there in writing plain as day. Others try to play hide the ball -- give an agent the chance to spin the yarn, and it indeed is going to happen. That's why I prefer the approach of the companies that are as straight-up as possible about what they will not cover.

Because you just can't trust health agents don't you know?

[somarco]

Golden Rule did in fact pull out of several states (as have AMS and other carriers). GR pulled out of GA about 3 years ago, then re-entered with new plans (filed with the DOI as non-association plans).

During the time they were "out" of GA they did not write new business. But they continued to service existing policy holders.

Prove that GR cancelled all existing policies when they exited LA.

I personally think you are full of ****.

[jbage007]

Originally Posted by somarco

Golden Rule did in fact pull out of several states (as have AMS and other carriers). GR pulled out of GA about 3 years ago, then re-entered with new plans (filed with the DOI as non-association plans).

During the time they were "out" of GA they did not write new business. But they continued to service existing policy holders.

Prove that GR cancelled all existing policies when they exited LA.

I personally think you are full of ****.

If they did not cancel all existing policies, then they did not "pull out" (remember that little game from junior high)?

It's typically a 5 year minimum to re-enter after a true pull-out (in most states). Sounds to me like the GA deal was more of a self-imposed moratorium.

Ahh, AMS. Let's see, by blood or maybe marriage it is, that would be, hmm, let's see, oh yeah, the golden company's sister.

I don't need to prove anything to you. If you want to prove anything, prove they did NOT term every existing policy. That is generally the reason a company pulls out.

They could not cancel just one policy. It's all or nothing man. What rock have you been living under?

In case you haven't noticed, I really don't care what some little GA health agent thinks about me. Like a famous trucker once said: You drive your truck and I'll drive mine. But thanks for your input.

[somarco]

Just an update.

A few years ago the LA DOI decided they did not like some of the language in the policies and told GR they could no longer sell, or renew, those policies in the state. UHC came back with the same policy structure, with the same language which was approved.

Many of the older policies aged off the books at renewal (in compliance with the DOI) while some were rewritten under the UHC brand.

[djs]

It's not uncommon for a carrier to pull out of a state. Doesn't happen every day, but it happens often enough. My guess is, you would be hard pressed to find a carrier that hasn't done it at some point, or at least threatened to do it, if some piece of legislation wasn't changed.

A while back, all of the major home insurance carriers pulled out of California, due to a mandate from the legislature that they underwrite earthquake insurance. Basically, the government tried to tell carriers how to run their business. Carriers said we don't tell you how to run the state, and left. The legislature gave in, changed the rules, the California Earthquake Authority was born, and the carriers came back.

The fact a carrier pulls out of a state should not be seen as unethical by itself. GR didn't pull out for one cancer case, as is implied. Of course, this by no means makes the statement that health carriers are completely ethical either

Dan

[Dave020]

In California, three carriers "pulled out" so to speak and closed blocks of business. Principal, Cigna and Aetna. Of the three, only the Principal did an honorable thing.

When Principal pulled out of CA IFP, they made an agreement with Blue Cross CA to take on the entire block of business. Blue Cross offered GI move over at +50% pricing or the opportunity to get standard rate through underwriting. Either way, you were covered.

Cigna was the most aggregious, they literally dumped about 4,000 people onto the MRMIP rolls who were uninsurable. I remember calling them about this before they left and was told that they had zero interest in making any provisions for their insured IFP clients.

Aetna, as I recall, stopped selling but continued to service existing policyholders. No new enrollments for several years.