Ship's Doctor and Insurance

[karfest]

On our recent Star cruise, my daughter had a day of fun in the sun (with sunscreen!)in Cabo and woke up the next day with a severe sunburn. We went to the ships medical center when her eyes swelled up and she began to blister. I had never used these facilities before and I must say the staff was really great and I was impressed at this "hospital" they have onboard.

 

Anyway, they gave me a sheet of paper that listed what the problem was, what they did, and how much it cost. It was only $60.00 including the naproxen they gave her (which is quite reasonable for an office call). I was told to turn this into my insurance company and they would re-imburse me.

 

Well, today I received a letter form my insurance company stating they denied the request becuse they need more information from the service provider. Here's my dilemma-

 

Should I just not fight it because it's already been paid (by us) or should I attempt to fight the insurance company? How would I contact my "service provider", NCL, to get more information. I can't imagine the customer service department could handle this one!

 

Why would insurance need any more info than the doctors name, diagnosis, etc? Are they just hoping I'll drop it?

 

Do I sound frustrated- cuz I am!!!

[shoreguy]

Why would insurance need any more info than the doctors name, diagnosis, etc? Are they just hoping I'll drop it?

 

Do I sound frustrated- cuz I am!!!

 

Yes - they know you can't get more info - teach them a lesson - call the company and start the escalation. You can provide any info they might need - Cabo- Sun - blisters- eyes ......

 

If you have cruise insurance they should cover.

[2Cruise4Ever]

Karen ~ two things: first, did you purchase travel insurance prior to your cruise? If so, you can file it with them also. If not, in my experience with insurance companies, they typically deny a small percentage of cases "just because." This one was somewhat unusual because you were at sea at the time. $60 really is not a lot of money when you consider the actual cost of insurance in the first place. But, if it were me, I'd fight it. Insurance companies go by diagnosis "codes" to determine what is "reasonable, allowable, and customary." Since NCL employes non-U.S. doctors (typically), they probably don't know what the "diagnosis" code is (AKA "ICD Code.") First, call your DD's doctor to obtain the correct diagnosis code that can be filed with the claim. Then, call your insurance company with that code. That SHOULD be enough. Everything is electronic these days. So, the insurance companies cannot issue a check to you without the ICD code (computers, gotta love 'em :) ).

 

 

Hope that helps.

[karfest]

I am one of those people who always buys cruise insurance just in case. Well, now I had a just in case and I FORGOT all about my cruise insurance. Thanks to both of you for your great information!!

 

I still would like to fight this with my insurance company becasue they do this type of thing alot. I have never had a claim go through the first time. THere's always a wrong code, need more info, blah, blah blah.

 

My first thought was to drop it but now I might fight. If that doesn't work - I'll actually get to use my cruise insurance:D

 

How would I ever get through life without this board???

[Hollyspop]

My two cents worth. If you are paying for your own insurance I would simply advise the company that if they do not pay the bill then I would be looking for a new company to handly my medical insurance.

[Host CMLA]

My two cents worth. If you are paying for your own insurance I would simply advise the company that if they do not pay the bill then I would be looking for a new company to handly my medical insurance.

Great idea but unfortunately not a good leverage tool in my opinion. I'm self employed and have paid my own personal insurance since 2000. Now I'm pregnant and I found out that individual policies (not group) do not cover prenatal care. So we have to pay for every expense. Do you have any idea how expensive it is to have a baby!?!? :o Needless to say, I was upset with my insurance company and told them that I would just go to another provider that valued me as a customer. I was then flippantly told that no company in CO covers prenatal care for independent insurance holders and I'd be foolish to switch now because then none of my other medical needs would be covered if I had pregnancy complications. And he was right. No one selling independent coverage in my state covers prenatal care. I'm just another number to the insurance company and if I leave, there's someone else to take my place. :(

 

Karfest...could it be that it was denied because it was out of network? IE: not one of the approved doctors? And would it be better to use the travel insurance to make the claim because the travel insurance provider won't raise you rates in the future whereas your insurance company may bump you up?

[niya305]

How would I contact my "service provider", NCL, to get more information. I can't imagine the customer service department could handle this one!

 

Why would insurance need any more info than the doctors name, diagnosis, etc? Are they just hoping I'll drop it?

 

Do I sound frustrated- cuz I am!!!

 

You can contact NCL Guest Relations to get the info you need

Direct toll free number:1-866-625-1164 (USA/Canada)

[1cruiselvr]

Fight it and you will win. I had a similar problem with a cruise medical claim with my insurance company and EVERYTHING they needed was on the form provided by the CL doctor. They also delayed the claim saying they needed further information. When challenged they could not tell me WHAT exactly was missing. After I challenged them, it was resubmitted to the 'foreign claims' department and voila - payment arrived in the mail approx 30 days later. Sometimes private medical insurance isn't educated on how to process this type of claim, so I highly suggest that you fight it. Mine was less than $100 also, but for me it was the principle of the issue. I have medical insurance, they should pay it. HAPPY SAILING!

 

PS They wanted to know why I didn't visit a land doctor for the ailment. I told them the symptoms developed while at sea for 5 days, so there was no opportunity. Nice try insurance company.......

[karfest]

Thanks to all of you for the advice. My insurance company is closed until Tuesday so I have plenty of time to prepare! I have a 90/10 co-pay and since this was out of network (way out of network!) they should pay 80/20. The dollar amount isn't much but now it's going to be a mission to get this paid- just so I can say I beat them at their little game!

 

I do want to reiterate that the doctor and nurse were fantastic. I hope I don't have to visit them again, but I was impressed with the facilities. It's not an area you think about when planning a cruise, but it's nice to know it's available.

[dosi]

it's going to be a mission to get this paid- just so I can say I beat them at their little game!

 

 

In my opinion, Karen, I don't believe it is a game. It is a standard procedure and believe it or not in the long run it helps your insurance rates from going up. I am guessing that possibly in addition to an ICD 9 code the insurance also needs a procedure number. Every medical procedure has a corresponding number. Each number has an allowed amount (how much the insurance will pay). Your insurance company needs to know exactly what was done and why in order to pay you back your 80% (of their allowed amount).

 

While I realize that this seems like a lot of rigamaroll for something that should be simple it actually helps contain costs. If the insurance company allowed payment to be based on what doctors bill rather than what they feel is usual and customary then there might be no cap on what unscrupulous doctors charge and therefore what insurance would have to pay. This would result in even higher premiums than we all pay now.

 

I know it seems like the insurance company is just trying to toy with you til you give up but I really don't believe this is the case. I worked for a large health care plan for many years (one of the big Blues) and I have written or called dozens of doctors and patients for additional information. The flip side of this is they just arbitrarily use the least paying procedure and then you get a small check. At least they have taken the time to ask which could actually work in your benefit.

 

 

Additionally they made need some clarification of liability. If the diagnosis simply shows burn as opposed to sunburn the insurance company wants to know that the burn was not at the fault of someone else (in this case the cruise line).

 

I would call the insurance company on Tuesday and explain that this was a medical visit on a cruise ship and that it will be difficult to contact the doctor directly as he is at sea. A good rep should be able to help you with this right on the phone as it is a small dollar claim and really will cost the insurance company more should they decide to drag it out. Good luck.

[raria]

Many policies do not cover if outside the U.S. and its territories

so they will need to know where you were when the

doctor rendered his services. Also, is the doctor registered

in the U.S. Is he a prefered provider etc.

[cruizinpooh]

I worked for a large HMO for 9 years in the Grievance and Appeals Department so I dealt with this many many times. Insurance policies usually only cover you within your service area UNLESS it is an emergency. Therefore, if you leave the country and for whatever reason you must seek medical attention (emergency) you are covered.

 

Problems you may be encountering:

 

1- You do not have a HCFA1500 claim form. (It is a pinkinsh-red and white form with a zillion boxes for information). This form needs to be COMPLETELY filled out including the ICD-9 (Diagnosis code) and CPT code (Procedure done- i.e. Office visit, Emergency room visit, EKG, etc etc etc.....

 

2- In a perfect world, this form should also include the Doctor's Federal Tax ID. This could be one of the other problems, as the physician that attended your daughter may not have one as they are to only attend to patients in International waters.

 

Regardless, you can obtain all this information from NCL and send it back to your Insurance company along with copies of your receipt for payment and a letter to the Grievance Department.

 

This is a claim that they must process manually. It will never be approved by any insurance company as it is an odd claim.

 

You are not alone. It is definately a very frustrating and may seem as a bit cumbersome process. However, it is normal. Not to say that you are one. However, you'd be surprised how many cases we dealt with where people would go and have plastic surgery and then submit a claim for saying they had an emergency. It obviously wasn't $60.00 but still denied until we were able to obtain more information.

 

So, don't give up!

 

Hope this helps.

 

Cruizinpooh

[tigerlilycruiser12]

cruzinpooh

 

YOu are right on. It is so difficult to collect money for services if you are a provider of services. those HFCA1500 claim forms have to be filled in just right.

 

Karfest

You can find the Icd 9 codes on some insurance web sites. If you can not find them then go to a book store and find the DSM 5RV and you can look up the codes for what you are putting a claim in for. Not sure if the insurance company will accept that from a consumer of services rather than a provider, but like cruzinpooh said you can try.

 

Good Luck

marie

[juliejoe]

Karfest,

 

IMHO - you may find when you call them Tuesday that the response you received was computer generated by someone who just did not take the time to understand your claim. Ask them what additional information they need and you may be able to provide it by phone or fax. $60 for any kind of an office call is not going to be considered in excess of usual and customary. If they need a statement that it is not due to an accident and there is no liability claim, you can send that along to them. If they need more information about the physician - NCL should be able to give that to you. I'd bet they have received calls before from folks whose insurance company wants more information.

 

We have used the medical facilities on ship several times and have filed claims successfully. Before submitting the most recent claim, I called our current HMO and explained the situation. They told me what I needed to file and I sent it along. When we had a POS they applied it to a deductible because it was out of network and paid nothing. Once I had a statement denying payment - I sent that, along with a copy of the bill to our cruise insurance and they paid it in full. Most cruise insurances are going to be secondary and want you to file it with your regular plan first.

 

It can be a nuisance, but you pay insurance premiums and you deserve the benefit of the policy - just have to follow their rules.

 

Good luck!

Julie

[1cruiselvr]

The information provided above is correct - for a US claim. My CL form from the doctor just had the medical diagnosis written out with the doctor's signature, date of treatment and that was enough to process the claim. So don't be put off by the code info. They don't need it to process a foreign claim. I don't even think countries outside the US use those codes. Happy Sailing!

[Sailaway...Sailaway]

You mentioned that you would have to pay 20% if you used your own health insurance. You also said that you purchased cruise insurance. I would tend to go with that one, first of all, because you probably won't have anything out of pocket, and because it's "travel/cruise specific". They should be more aware of how these things are billed, etc. And, that way you can save your health insurance for covered visits and illnesses on land. That would just be the way I would do it. :) :)

 

In my opinion, Karen, I don't believe it is a game. It is a standard procedure and believe it or not in the long run it helps your insurance rates from going up. I am guessing that possibly in addition to an ICD 9 code the insurance also needs a procedure number. Every medical procedure has a corresponding number. Each number has an allowed amount (how much the insurance will pay). Your insurance company needs to know exactly what was done and why in order to pay you back your 80% (of their allowed amount).

 

While I realize that this seems like a lot of rigamaroll for something that should be simple it actually helps contain costs. If the insurance company allowed payment to be based on what doctors bill rather than what they feel is usual and customary then there might be no cap on what unscrupulous doctors charge and therefore what insurance would have to pay. This would result in even higher premiums than we all pay now.

 

I know it seems like the insurance company is just trying to toy with you til you give up but I really don't believe this is the case. I worked for a large health care plan for many years (one of the big Blues) and I have written or called dozens of doctors and patients for additional information. The flip side of this is they just arbitrarily use the least paying procedure and then you get a small check. At least they have taken the time to ask which could actually work in your benefit.

 

 

Additionally they made need some clarification of liability. If the diagnosis simply shows burn as opposed to sunburn the insurance company wants to know that the burn was not at the fault of someone else (in this case the cruise line).

 

I would call the insurance company on Tuesday and explain that this was a medical visit on a cruise ship and that it will be difficult to contact the doctor directly as he is at sea. A good rep should be able to help you with this right on the phone as it is a small dollar claim and really will cost the insurance company more should they decide to drag it out. Good luck.

[dcd34]

No one selling independent coverage in my state covers prenatal care.

 

I'll bet they cover *****, though.

 

Wonderful system we have here.

[shoreguy]

You mentioned that you would have to pay 20% if you used your own health insurance. You also said that you purchased cruise insurance. I would tend to go with that one, first of all, because you probably won't have anything out of pocket, and because it's "travel/cruise specific". They should be more aware of how these things are billed, etc. And, that way you can save your health insurance for covered visits and illnesses on land. That would just be the way I would do it. :) :)

 

Many of the travel policies are set up as secondary coverage. Read the policy. What that means is they only cover expenses that your primary carrier does not.

 

Good luck collecting - Even if the primary denies the claim for lack of information the travel company is going to take a position that they should and it is not their problem.

 

Let's face it it is all about business and nothing to do with healthcare. Every dollar not paid out goes to the bottom line minus the cost to keep from paying the claim. :(

[Host CMLA]

I'll bet they cover *****, though.

 

Wonderful system we have here.

Ya know...I checked and they do cover ***** and related treatment. However, today, as I pay my $941.26 bill for four blood tests I had done a few weeks ago to test for birth defects, I'm having trouble finding any silver lining. :rolleyes:

[shoreguy]

Ya know...I checked and they do cover ***** and related treatment. However, today, as I pay my $941.26 bill for four blood tests I had done a few weeks ago to test for birth defects, I'm having trouble finding any silver lining. :rolleyes:

 

And we wonder why so many women have no or very little prenatal care in this country.

[cruisingfromMN]

You mentioned that you would have to pay 20% if you used your own health insurance. You also said that you purchased cruise insurance. I would tend to go with that one, first of all, because you probably won't have anything out of pocket, and because it's "travel/cruise specific". They should be more aware of how these things are billed, etc. And, that way you can save your health insurance for covered visits and illnesses on land. That would just be the way I would do it. :) :)

 

The cruise insurance will be secondary to your primary insurance. So whatever your primary does not cover, the cruise insurance will.

[dosi]

Ya know...I checked and they do cover ***** and related treatment. However, today, as I pay my $941.26 bill for four blood tests I had done a few weeks ago to test for birth defects, I'm having trouble finding any silver lining. :rolleyes:

 

 

Next time get those tests done while you are on a cruise Cecilia!!! Then bill them to your travel insurance......hehehe. ;)

[Host CMLA]

Next time get those tests done while you are on a cruise Cecilia!!! Then bill them to your travel insurance......hehehe. ;)

Doris...you're a genius! I wonder if I can get myself on a cruise before next Tuesday when I have to pay $150 to see my doctor and another $200 for our first ultrasound? :D

[shoreguy]

Doris...you're a genius! I wonder if I can get myself on a cruise before next Tuesday when I have to pay $150 to see my doctor and another $200 for our first ultrasound? :D

 

with your luck they will turn down the claim - Pre-exisiting condition ;)

[Host CMLA]

with your luck they will turn down the claim - Pre-exisiting condition ;)

Funny you mention that because pregnancy is no longer considered a pre-existing condition. Huge court case a few years ago brought on by women feeling discriminated against because they couldn't change jobs and get insurance because they were pregnant. Now just as insurance companies factor in that a certain percentage of patients will have cancer, they have to factor in that a certain amount will be pregnant and rates reflect that. Of course, that's if you're in a group plan that covers prenatal care at all. I'm not so pre-existing or not, I need about $15,000 between now and October. Maybe I should bid out for naming rights? If Nestle pays the money they can name the kid TollHouse. LOL :D

 

Karfest...sorry to be so off subject. :o What happened when you called the insurance company yesterday?