Visitors Insurance - Post Purchase Help

Here is one simple example of how we as a broker provide post purchase help to our customers.

Customers who purchase visitors insurance for their visiting relatives are many times dissatisfied for no justified reason, primarily due to their lack of understanding of healthcare insurance in general, and not even anything specific to visitors insurance.

We once received a call from a customer who expressed extreme dissatisfaction with the insurance company. He told us that they are not paying his claim and are telling him to pay everything. On top of that, the doctor’s office is after him to pay immediately. He stated that the insurance company is committing fraud and that their insurance is a scam and that he would tell everyone he knew not to buy insurance from this company.

Upon discussing further with him, we found that that he had already received his Explanation of Benefits (EOB). We asked him to forward it to us and we reviewed it. We discovered that everything was done properly according to how it should have been done.

He took his mother for Dr.'s visit and there were some tests also involved. The total bill was $393.00. As the Dr.'s office was participating in the PPO network, $248.29 in-network discount was applied and the total bill was reduced to $144.71. As the insured's deductible is $250, and the bill amount is below that, entire $144.71 would be the insured's responsibility. Of course, in any insurance plan (whether it is visitors, health, or even auto insurance), it is very well established that you must pay the deductible before the insurance company starts paying anything at all.

He took this as insurance company not paying claims and accused them inappropriately. Of course, everything was done as it should be and we found nothing wrong with the entire situation.

He still had further difficulty in understanding why the charges were reduced. Providers (Dr., hospital etc.) bill a certain amount to the insurance company. If the provider is in network, instead of charging any amount they like, they have to charge network negotiated fees which have been negotiated between the insurance company and the provider. On the other hand, if the provider had been out of network, the total charges would still be $393.00 and the customer would have to pay first $250 in deductible plus 20% of the balance (as per the insurance he purchased). Therefore, he would end up paying $278.60, which would be a lot more than $144.71 he would end up paying otherwise. However, I guess he probably would have been happier that the insurance company paid at least $114.40.

Most people may not know this, but on a side note, in order to get $248.29 in-network discount, the insurance company had to pay 18% of that amount to the PPO network company to negotiate on their behalf and get them a discount. Therefore, it is not like the insurance company didn't pay anything.

In any case, we are glad that the customer was finally convinced that everything was processed accurately. We are glad that, as a broker, we were able to help this customer at the time of his claim.