Surprising discovery about my health insurance

Being on vacation for all of December, being bored, I made the mistake of looking at an Explanation of Benefits from my Health Insurance company. It seems they're not paying anything on the Insurance claims filed by the health provider for my wife.

I called Aetna for an explanation. It was explained that If my wife's employer's insurance paid more than what Aetna's considered customary and reasonable charges than Aetna will not pay anything. I had to ask the represenative why I was paying premiums for coverage for my wife if Aetna wasn't paying anything because she has her own primary coverage. Evidently Aetna gets quite a few inquiries about this conumdrum. The represenative said that they have to advise clients calling about this situation that the clients need to examine the cost of premiums in relation to the benefit received. There is no benefit.

My company is self insured and Aetna adminsters the Health insurance, not knowing if this is standard policy for all Aetna Health Insurance.

I have Aetna. They are by far the best I've dealt with.

My wife had double coverage through me and her job. Not only did it not add any benefits but it confused the insurance companies. She dropped her insurance and her work pays her $200 a month for dropping it. Same benefits plus $200 a month in our pockets.

Whilst there's no benefit in being under insured, there is clearly no benefit in being over insured either. Being double insured for your health probably has no benefit at all - as you've found out. I'd be inclined to drop one or the other and save the premiums, just as Snidely333 has suggested. Imagine how much more blackjack, craps and slot play you can get in over a year with the money saved. :-) That's a form of insurance for sanity of mind, if not safety of body. Merry Christmas by the way!

No surprise here Insurance companies are dishonest and unethical.

Not quite so unethical as they never tell you their rules.......

Good responses, thank you all. I take ownership of paying for something that has little or no value. Every October, when the options of electing the benefits for the following year are offered, I ignore it. I don't read the brochure sent to me. I leave everything the same as It has been for 23 years. I'm extremely busy and also I'm extremely lazy when it comes to that stuff.

We're blessed with relativley good health and never scrutinized the outlay of money spent for visits to health providers.

Talking wtih a friend of mine, he did make a comment that the Insurance companies have to make a profit for the shareholders. Simply put, they have to bring in more revenue than what they pay out and the most popular business model is one that puts a large emphasis on rejection of claims.

I used to have Horizon Blue Shield. Every claim I sent in they rejected and made me fill out a form stating we had no other insurance coverage. Aetna doesn't pay the service providers much but they process the claims quickly.

When my wife had two insurance companies, they would fight over who was supposed to cover her. Her boss, an attorney, felt that since we were paying for full coverage from both of them that it should be up to us to choose which company to file the claim wiith. How can an insurance company accept your premium but then deny you coverage?

If you read the contract most of them go into to great detail over who pays if there are multiple policies at play.

As far as the not paying for charges because they are not reasonable and customary unfortunately it is one of those terms that allow them to get out of paying for any reason because the policy also allows the insurance company to define what is reasonable and customary. Another big one is “experimental” treatment. I once got a claimed denied because my treatment was considered “experimental” by the insurance company. I did some research and found out my “experimental” treatment had been standard medical practice for the last 20 years, but in the end it made no difference because the policy allowed the insurance company to define what the term “experimental" means. Basically any procedure they don't want to pay for is “experimental”.

In the end most people are in the boat that Cjen is in that they are in fairly good health and they don't realize how poor our insurance system is until something unexpected comes up, and then it is too late. In the case of group insurance provided by an employer the insurance company can flat out not pay for whatever reason and you can't even sue them your just SOL.

I have a personal policy that the service provider is only entitled to reasonable and customary charges so that part of it doesn't bother me. Sometimes I have to explain my personal polity the service providers numerous times but they eventually stop sending me bills after they realize they cannot justify these excess costs. WHen I walk into a doctor's office, I'm not writing them a blank check for whatever they think is acceptable. If the insurance company doesn't have to pay the bill in full, why should I be responsible for these over charges.

In all that i've been though the last 2 years,our insurance hasn't blinked but a few times.and those were settled quickly with little more than a phone call.

JOHN

PS BUT... if you're illegal and at a dialysis clinic then you're OK. All paid for.