Health Insurance issues

If you have Health Insurance, will you have no issues in case you have any surgical procedure?

Unfortunately for my family, the second semester of last year was not good in terms of health. Since the end of 2021, my wife had been declared a healthy post-menopausal woman. But at the end of June 2022, she had abnormal uterine bleeding that worried us a lot. We called her gynecologist (who is also an oncologist) to perform an emergency review. She underwent several studies that day and the following weeks. The final diagnosis was that she had a polyp that had to be removed by surgical procedure.

Due to the above, I contacted my insurance agent (since that is the process to be followed by the insurer) to request approval for the surgical procedure, and receive a "hospital authorization letter". Many papers had to be filled out and submitted (study results, letters from doctors, forms, etc.). Everything was presented a month after the bleeding began and in a "digital" way (8 documents were scanned and sent by email).

Second Sending of Information

After 10 days of sending the information, the insurance agent requested a justification from the treating physician since they did not understand the reasons for the surgical procedure, which was already explained in the medical report (under the format of the insurer) and with the results of the laboratory studies that corroborate it. In any case, we asked the doctor to send us a letter explaining in a very understandable way why this procedure was justified. They were also annexed to more laboratory studies that my wife continued to perform.

After another 10 days, our insurance agent informed me that the surgery has not been authorized. Therefore, the decision was made to escalate this matter within the insurer, since the reason for its response is not explained, when all the required documents, studies, and explanations have been delivered, according to their process.

Third Sending of Information

More days passed and the escalation did not work. I was very annoyed, so I start to write a letter of complaint to the insurer, applying the terms that the same doctor mentioned in her writings, but in such a way that a person with a “primary education level” would understand them. I also wrote it in such a way that it would work as a legal backup, in case the authorization was rejected for the fourth time. This letter was sent again with all the documentation (15 documents in addition to the letter of complaint). At this time, it had already been 2 months since my wife had her first bleeding. In those moments, I was asking myself, what would have happened if this was something more urgent?

Hospital Authorization Letter

Finally, after submitting the same information several times and they were not reading it or did not want to understand it, I received the first letter authorizing the surgery, but the amount of Medical Fees to be paid by the insurer is zero (???), and the percentages that I should pay for hospital services were not correct. For this reason, my insurance agent requested clarifications to our concerns about this first letter. But, with that authorization, we began to carry out the pre-surgery studies and the date to be done. According to the hospital’s surgery room’s availability, it was planned for the end of September. Yes, 3 months after the bleeding started.

In the first days of September, the second authorization letter was received, but still with the number of Medical Fees in zero, as if the insurer was not going to pay for it. We received the third authorization letter while we were already in the hospital and after my wife already had the surgery. In those moments, we were told by phone that we must request the medical fees refund. What?!!! We had to pay for it and then wait for the refund.

Conclusions

We never really understood the insurance company's processes. Why is there a surgery programming process with the delivery of an authorization letter, if in the end, a refund must be processed? If I had known all this before, my wife would have had surgery in July and not in September 2022. We were very angry with the service provided by the Insurer since they do not know how to process health claims for their clients due to the lack of the minimum knowledge in health, essential for this product.

What are the main problems that this insurer has?

1. Not many people understand what Digital Transformation is and are confusing it with business digitization (converting current processes by eliminating paper and using the simplest technology available to reduce costs). The main problem with it is that the internal processes are usually not focused on the customer experience (CX) or the employee experience (EX) since the information is only scanned and converted to a format through which it can be sent by email. That is not Digital Transformation.
2. Digital Transformation is the Business Transformation to become more Agile centered on the Customer and enabled by Technology creating and capturing new opportunities (Value / Innovation) while being more Efficient (in cost, time, and agility) mostly based on Data with an enhanced approach to Risk Management.
3. Digital Transformation also covers the organizational culture, where the following should be done:

• Review or reinvent all the processes (internal and external) of the organization,
• Make an inventory of the required skills of the personnel and establish a training plan,
• Review and change current systems and infrastructure that impede business innovation, flexibility, and agility.

I offer you to review your culture, processes, and/or technology to create a specific strategy and roadmap for your organization with a customer-focused approach, improving the quality of life of employees (innovating and being more efficient) through the use of data, all this enabled by the technology that best suits your needs.

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