North Carolina Health Insurance Case Studies
This section presents a few specific examples of the kind of cases we deal with, how we go about working with a variety of situations, and the type of results we strive for. Whether they seem straightforward or unusual to you, for us they’re “business as usual”.
Click here for Individual case studies, and for group case studies, click here.
If you’d like to know more about the specific products and carriers we deal with, click here.
Individual Case Studies
Case Study 1 – Multiple health conditions, carrier denial of coverage
Background
Our female client had multiple non-severe health conditions, and was looking for health insurance. Initially she conducted her own research, and applied to carriers directly. Each application involved a long, drawn-out process requiring her to assemble comprehensive medical history records, and compile and submit extensive paperwork. Because of her various conditions, she was denied by all carriers. After 6 months without success, she approached John F. Sipp & Associates on the advice of a friend of a friend.
Our Approach
The first meeting lasted a couple of hours, during which we gathered all the background of her medical history and her attempts at getting coverage. We then researched her options, and presented them to her in a second meeting. We chose one, and made an application to an individual carrier. However, the application process started delving into her medical history in some detail, and put our client on an emotional roller coaster. Because of her discomfort, we told her that if it was something she didn’t want to go through, we could stop the process and explore other options. So we did.
After much further discussion and exploration of a wide range of creative solutions, we realized that she owned an LLC. This gave us the option of writing a one-person guaranteed issued group policy. By writing her a policy this way, we were able to answer medical questions without the invasive emotional medical interview, so she did not have to relive uncomfortable medical memories. There were no telephone interviews, no requirements for extensive medical history, and while it was time-consuming, it was not nearly as time-consuming as writing an individual policy.
Outcome
The premium on the individual policy we were applying for was in the region of $1,850 a month. The one-person group policy was around $500. So our client saved over 70% by taking this approach.
In addition, the plan benefits were richer than the individual policy in the long run.
We maintained her on this policy for several years, before moving her on to a Medicare supplemental policy.
Case Study 2 – Pre-existing condition requiring surgery, carrier refusal to pay claims
Background
“John F Sipp & Associates have always been accessible and able to answer our questions in a timely manner. They always take my calls and always have the answers I need. They have played a large role in my search for lower insurance rates and are always eager to find the best options for us.”
A 34-year-old female, after working for the state and being on their insurance plan for 5-7 years, decided to make a career change. Since COBRA was too expensive for her, she came to us and we wrote her a short-term policy, which covers catastrophic and major medical costs, and, at the time, covered pre-existing conditions.
She then had to undergo an unexpected surgical procedure, and she approached us to help file her claims.
Our Approach
We submitted the claims, but the insurance carrier denied them all. The bills amounted to around $12,000, a sum that our client simply did not have.
So we took up the case directly with the carrier, trying to understand why they were denying the claims. However, after many phone calls, many hours, and long explanations from the carrier, they still wouldn’t budge and agree to pay the claims.
So we wrote letters to the carrier, and filed a grievance with the North Carolina Department of Insurance. We followed up, to make sure our case was getting attention. And with patience and persistence, we managed to get the claims paid.
Outcome
We advocate on their behalf of our clients when the situation requires it. In this case, we were able to relieve our client of a significant financial worry by being persistent and going through the right channels to get it resolved. Our client was so concerned about it that when we told her that the claim would be paid, she broke down with relief.
The client has since moved on to a permanent job with a group policy, but she still corresponds with us.
A final note: Since this case took place, legislation has been passed that removes pre-existing conditions from the coverage provided under short-term policies.
Case Study 3 – COBRA expiring, major surgery required, inability to afford high premium
Background
“A health insurance agency with a heart! Always available with helpful and friendly advice.”
A self-employed man with a hardwood refinishing company was insured under his wife’s group policy with her employer. However, she lost her job, so they took out COBRA to continue their coverage.
The husband developed a severe infection in his leg, and the doctors told him that the leg would need to be amputated. However, their coverage under COBRA was about to expire, and the premium for the one carrier they applied to was more than they could afford. So they approached John F. Sipp & Associates to investigate options for them.
Our Approach
We knew that, with COBRA about to expire, we had to find coverage within the 63-day grace period, after which his pre-existing condition would not be covered. We also knew that an individual policy that would cover his condition and the upcoming surgery would be prohibitively expensive.
Because the husband had an LLC for his business, we were able to write a one-person guaranteed issued group policy. And because we set the policy up within the 63-day grace period after the expiration of COBRA, there was no lapse in coverage, so the pre-existing exclusion clause did not apply.
Outcome
Unfortunately, the leg did have to be amputated, but the procedure was covered under the one-person group policy.
The cost of an individual policy for the husband was around $1,800 a month. The one-person group policy was $400. So we managed to save our client over 75% and get his procedure covered.
Even though the wife has since moved on to a new job with group coverage, the husband has chosen to stay on the one-person group policy to ensure that he has continuous coverage.
If you’d like to know more about the specific products and carriers we deal with, click here.
Group Case Studies
Case Study 4 – Group: Employee with significant unpaid claims for cancer treatment
Background
An employee of a company with a group plan written by John F. Sipp & Associates had the misfortune of developing a rare type of lymph node cancer. This required extensive radiation, chemotherapy, physical therapy, and other treatments.
During her many traumatic hours of treatments, she was physically unable to follow her claims to make sure that everything was coded and processed appropriately by the medical facility to the insurance company.
She asked us for assistance in resolving over $30,000 of unpaid claims, involving well over 100 pages of claims that had been denied or only partially covered.
Our Approach
On examination of the policy, we discovered that she had used providers covered under the policy, and that she was liable for a maximum of $3,000 of out-of-pocket expenses.
Through frequent phone calls and persistence, we badgered the insurance company until we were finally put in touch with a claims specialist. These people seldom, if ever, deal directly with the public or with brokers.
We went through every page of every claim with the claims specialist, and discovered that many of the services had been coded incorrectly. So we recoded the claims and resubmitted them.
Outcome
The claims were eventually paid as per the policy, liberating the employee from a $30,000-plus headache. The claims specialist drove all the way from Charlotte to the employee’s home in the Triangle to deliver the claim payments and apologize to the employee for her inconvenience.
Case Study 5 – Group: Significant savings on company and individual premiums
Background
“Thank you for your on-going annual support in evaluating our health insurance needs. It is nice to know that we are always getting the best coverage for our organization and at the best price.”
A young and small technology company with 11 employees had a policy with a carrier that was no longer competitively priced. They approached us to help them investigate cheaper options.
Our Approach
We shopped around, pricing plans with various carriers that we represent.
In addition, the existing plan covered employees, but required them to pay the premiums of their dependents. These premiums were very expensive. Upon further investigation, we discovered that they were all in good health, and so we researched individual policies for the dependents.
Outcome
We rewrote the group plan with a carrier that gave them an annual savings of 10-15% (nearly $5,000), a significant savings for the employee group involved.
We were also able to write individual policies for the dependents, resulting in significant savings for the employees. This added bonus was a great PR coup for the company with its employees.
Case Study 6 – Group: Multiple health conditions, significant prescription costs, risk of lapsed coverage
Background
A novelist in her 50’s moved from the Midwest to NC, bringing with her pages of medical conditions, including diabetes, hepatitis and obesity. Part of her treatment regimen involved a $2,000-plus prescription drug that needed to be injected.
Our Approach
It was highly unlikely that we would have been able to find a carrier to insure her under an individual policy, and even if we could, it would have been prohibitively expensive. So we wrote her a one-person group policy.
However, because of her expensive medications, her prescription benefit ran the risk of maxing out early in the policy period. If it lapsed, her condition would have been classified as pre-existing, and the resultant cost of coverage would have left her bankrupt.
So we rewrote the policy multiple times a year to ensure her continued coverage.
Outcome
We went the extra yard to ensure that our client received continuous coverage at the best price available to her. The agent involved even called the client from her sick bed during a troubled pregnancy to manage her situation.
The client is now in assisted living, and because she can no longer afford health insurance, she is considering applying for social security disability. We are continuing to help her, providing guidance and advice in an endeavor that has no financial gain for John F. Sipp & Associates.
If you’d like to know more about the specific products and carriers we deal with, click here.
