Difficulties in Communication for Health Insurance Companies

Part 1: The Basic Tools, Chapter 2: Understanding the Language of Health Insurance Page 9

Continued from Previous Page

I recently helped another reader deal with a situation that also illustrates the difficulties that insurance companies some times have in communicating basic information to consumers. In this case, the reader was covered by a private insurer. He had been in the hospital, and had been treated for a serious condition by several different medical specialists on the same day. The insurer, however, only paid one of the bills. The insurer explanation was that the policy provided coverage for only "one provider per day."

When I checked with the insurer, I discovered that the problem was really quite different. One of the claims had apparently been submitted without a diagnosis. According to an executive at the insurance company, the diagnosis that was eventually submitted was the same as the diagnosis on a claim for the same date that had already been paid. Since the diagnoses were identical, the second claim was denied. However, after review, the insurer determined that the reader was being treated for "multiple conditions" and that reimbursement for treatments by several specialists on the same day was thus appropriate. Interestingly, although the insurer's original explanation was that the policy provided coverage for only one provider per day, the policy did not contain any such provision. However, the comment that the policy paid for only "one provider per day" was one of the computer-generated statements available to be printed on an EOBS to explain the denial of a claim.

I think there's a desperate need to improve communication between insurers and consumers, particularly in terms of the messages in letters from insurers to consumers and on Explanation of Benefits Statements. Part of the difficulty is that those messages often make use of technical terminology. In addition, the messages in letters and on EOBS are often limited, are usually computer-generated, and are not written on a personal basis. Table 5 helps illustrate some of the technical terms that are frequently used by insurers in letters to consumers and in EOBS (See Table 5).

Continued on Next Page