Benefits, help!!

ruemorgan · December 2014

On Friday I had talked about how irritated I was that I cant use my short term disability towards maternity leave because my pregnancy is classified as "a pre-existing condition." Which means I would have had to enroll in short term disability back in October 2013 for the 2014 year when I got KU. I tried fighting three representatives on the phone over the matter, I got no where. It was black and white to them.

So, today I'm talking to two coworkers who are also expecting and seeing if they got approved. They didnt get automatically approved, but they are having it reviewed by an "authorized administrator." So, there is an option I wasnt offered.

Enrollment is now over as of today, but I feel like its unfair that their cases are being reviewed and I was shut down three times. The two coworkers also mentioned no one asked if they were currently pregnant, so they might not even be considered a pre-existing condition, which makes me feel like the enrollment process is not fair. Also, we are allowed to change our benefits under life changing circumstances and they do consider having a baby as a life changing circumstance, so I dont understand why the argument "you didn't enroll before you were pregnant" is valid.

Im going to end here before I get too ranty. So my question is how would you handle/fight the situation? I really dont want to screw this up since it looks like there might be one more chance at getting paid maternity leave approved.

chaysefaith · December 2014

I'd call your benefits center or talk to someone in HR. If you've been making phone calls previously hopefully there is a record somewhere that says you called and what you discussed so maybe they can still get you enrolled. Sometimes employers are willing to allow late enrollment in benefits based on different circumstances.

chaysefaith · December 2014

tunnel said:

Let me see if I have this right: You did not sign up for STD before getting knocked up. You tried to sign up for STD now that you are pregnant and they did not approve you because your pregnancy is a pre-existing condition. Sound very standard to me. Why on earth would an insurance company agree to pay you benefits for a pre-existing condition when you essentially have not paid the premiums they would expect for this type of benefit? It doesn't work that way.

What her employer is telling her is that she would have had to enroll in STD in 2013 to be covered for maternity leave in 2015. Because she is pregnant in 2014 they're saying she can't enroll in STD in 2014 for the 2015 benefit year because of a pre-existing condition. So she would be paying for the benefit in 2015 to use in 2015.

ETA: What I don't understand though is that electing STD in 2013 would have been only for the 2014 year, and then she would have had to enroll in it again in 2014 for the 2015 year, so still a pre-existing condition based on their logic.

peeppeeppeep · December 2014

tunnel said:

Let me see if I have this right: You did not sign up for STD before getting knocked up. You tried to sign up for STD now that you are pregnant and they did not approve you because your pregnancy is a pre-existing condition. Sound very standard to me. Why on earth would an insurance company agree to pay you benefits for a pre-existing condition when you essentially have not paid the premiums they would expect for this type of benefit? It doesn't work that way.

If I understand it right, I think the issue is really that other co-workers in her same situation were offered an option that she wasn't before the deadline, and that they may not have communicated all of the options with her. I don't think she's being unreasonable.

Whitfry · December 2014

When our enrollment period came up, I had recently started my job and I specifically asked about short term disability benefits. I was told I had to pay in for a year before I could get any payout. Since I was 17 weeks at the time, I obviously won't be getting paid during my maternity leave. But I don't feel jipped, since I was aware of how things worked. Does it suck? Yes. But it is what it is.

It sounds like even if you enroll now, you won't get a payout. I've not heard of not getting paid due to pre-existing conditions, but having to pay in for a length of time seems standard.

I would talk to your HR department or see what it takes to get the same review process your coworkers are going through. But just because their cases are being reviewed doesn't mean things will go in their favor.

colleen4019 · December 2014

My current STD coverage is through the state so I don't have current experience, however at a previous employer the 'rule' was you had to be signed up for std 1 year before you wanted to use it in order to get full coverage for any leave.
I do remember there being major issues during open enrollment because we were offered a new plan -which 2 of my pregnant co-workers signed up for. The new plan considered pregnancy as a pre existing condition so they no longer qualified for leave. Basically there was rioting when my coworkers found this out, neither was informed that the new plan would void their leave. I do believe that they were permitted to return to their previous plan and restore their eligibility for leave.

My point would be insurance companies suck and do everything they can to not pay for anything they can get away with not paying for! Talk to you HR and get someone on your side to help you navigate this issue.

chaysefaith · December 2014

tunnel said:

In my experience, most STD plans have a 3 month exclusion period, meaning you can't get pregnant for three months after signing up if you want to be covered. Those 3 months + 9 months of pregnancy mean that you will be signed up for STD for about a year before they pay out for maternity leave. OP said her open enrollment just ended, so assuming it took place at the same time in previous years, she would have had to sign up in Nov.m2013 to be covered. This is standard in my opinion.

This would make sense if there was a wait period where she would not be eligible to use the benefits.

It hurts my feels when people say things like "insurance companies suck." Insurance companies have exactly nothing to do with the benefits that you are offered by your employer or how much you pay for them. Insurance companies sit down with employers, go over all the things that can and cannot be offered, and the two companies together decide what that will cost the customers. From there all the insurance company does is follow the guidelines that were set forth by the employer. Mistakes happen and claims may get processed incorrectly but all you have to do is call the insurance company if you notice something is wrong and they'll correct it. Whether or not something is going to be covered is determined by the employer offering the plan. If an employer sits down and says "cover everything and we'll pay for it all" then that's what insurance companies do. If they come in and say "we don't want to cover chiropractic care, massage therapy, speech therapy, acupuncture, or bariatric surgery and we're going to split the cost of what we are covering with our employees" then that's what the insurance companies will offer and enforce.

/tangent

starsailorr26 · December 2014

It sounds like your coworkers have been told differently than what you were told, so I would speak to someone in HR for clarification. Regarding your coworkers, they might not have thought to ask or mention they were pregnant before they enrolled, but I'd be willing to be my lucky penny that when the time comes, the insurance isn't going to approve their disability claims for the pregnancy due to a pre-existing condition.

Keep in mind that even if you'd signed up in 2013 for 2014, you would have had to keep the plan for 2015 to get paid out on it. As pp said, most STD plans have the 3 month exclusion for pregnancy meaning you need to have the policy in place for a year before they will pay out benefits.Still, it's worth mentioning to HR or the Benefits person.

ruemorgan · December 2014

peeppeeppeep said:

tunnel said:

Let me see if I have this right: You did not sign up for STD before getting knocked up. You tried to sign up for STD now that you are pregnant and they did not approve you because your pregnancy is a pre-existing condition. Sound very standard to me. Why on earth would an insurance company agree to pay you benefits for a pre-existing condition when you essentially have not paid the premiums they would expect for this type of benefit? It doesn't work that way.

If I understand it right, I think the issue is really that other co-workers in her same situation were offered an option that she wasn't before the deadline, and that they may not have communicated all of the options with her. I don't think she's being unreasonable.

This is the most accurate summary. While I completely understand their policies and have accepted it, I dont think its fair they were given a different option than me. Even if they get declined, why wasnt I offered this option to atleast try. I want the same opportunities.

ruemorgan · December 2014

TikTak said:
I assume they were offered other options because they didn't tell the people they were pregnant.

I was asked if I was pregnant, and they were NOT asked if they were pregnant. I feel like that question should be universal if you will penalize someone based on the answer.

It sucks to see that I probably have no chance at changing the situation, but im atleast glad to have gotten a more practical view of the situation and other STD policies. Thanks for all the input. Im still going to call tonight and see what happens.

skootnshoot25 · December 2014

I work for a disability provider and worked in STD as well as have counseled employees on the benefit. Each policy is different but as a rule there is a pre existing period which means if within the time before the policy effective date (usually 3, 6, or 12 months) you have had diagnosis or treatment for the condition you are going out of work for, pregnancy included, the claim will not be paid. The waiting period is the time the policy has to be effective before a claim will be paid. And some policies have a look back period, usually the first year, and if you file a claim during that time they will look at the pre ex period to see if you were seen for that condition. Basically an insurance company is not going to sell you a policy that you will use in the first year for an existing condition. They wouldn't stay in business. It sucks if you are not covered for this reason, but it's why if you are trying to get pregnant, so many articles advise you to research your disability policy and get insured before you need it. Of course if you aren't/weren't trying then it might not have been on your mind way back then.

chaysefaith · December 2014

Meh. I don't want to hijack the thread and I really can't answer for anyone but myself, but I will say that (some) people who work in call centers talk to literally hundreds of people a day. Incorrect information is going to happen but that doesn't it mean it happens from the same person consistently, when you factor in the number of people they talk to in a week, multiplied by 52 weeks. Mistakes happen.

Maybe I'm just fortunate because I literally only handle one account, therefore I could answer those questions in my sleep.

skootnshoot25 · December 2014

chaysefaith said:
Meh. I don't want to hijack the thread and I really can't answer for anyone but myself, but I will say that (some) people who work in call centers talk to literally hundreds of people a day. Incorrect information is going to happen but that doesn't it mean it happens from the same person consistently, when you factor in the number of people they talk to in a week, multiplied by 52 weeks. Mistakes happen.

Maybe I'm just fortunate because I literally only handle one account, therefore I could answer those questions in my sleep.

This.

After a long holiday weekend everyone is on board, often with shortened breaks and longer days to handle the 30% increase in calls because not only is it a Monday and busier anyway but the call center has been closed for 2 whole days...so now everyone and their mother are calling.

Misinformation is never ok but it's like expecting identical service from anywhere anytime-you're bound to get different experience levels and focus depending on who you get and when you call. We are all human.

skootnshoot25 · December 2014

etoille said:

skootnshoot25 said:

I work for a disability provider and worked in STD as well as have counseled employees on the benefit. Each policy is different but as a rule there is a pre existing period which means if within the time before the policy effective date (usually 3, 6, or 12 months) you have had diagnosis or treatment for the condition you are going out of work for, pregnancy included, the claim will not be paid. The waiting period is the time the policy has to be effective before a claim will be paid. And some policies have a look back period, usually the first year, and if you file a claim during that time they will look at the pre ex period to see if you were seen for that condition. Basically an insurance company is not going to sell you a policy that you will use in the first year for an existing condition. They wouldn't stay in business. It sucks if you are not covered for this reason, but it's why if you are trying to get pregnant, so many articles advise you to research your disability policy and get insured before you need it. Of course if you aren't/weren't trying then it might not have been on your mind way back then.

Side note - I did actually confirm no prexisting/pay in for my policy. It might be something that's more characteristic of employer provided/paid coverage but this is the only experience I've had with two-three different employers at this point.

You may be right - I only have experience with my own company and the various policies they offer. It is good to confirm those items like you did. Even working in the business it takes time to understand everything so it's harder when you aren't in it every day.

colleen4019 · December 2014

chaysefaith said:

tunnel said:

In my experience, most STD plans have a 3 month exclusion period, meaning you can't get pregnant for three months after signing up if you want to be covered. Those 3 months + 9 months of pregnancy mean that you will be signed up for STD for about a year before they pay out for maternity leave. OP said her open enrollment just ended, so assuming it took place at the same time in previous years, she would have had to sign up in Nov.m2013 to be covered. This is standard in my opinion.

This would make sense if there was a wait period where she would not be eligible to use the benefits.

It hurts my feels when people say things like "insurance companies suck." Insurance companies have exactly nothing to do with the benefits that you are offered by your employer or how much you pay for them. Insurance companies sit down with employers, go over all the things that can and cannot be offered, and the two companies together decide what that will cost the customers. From there all the insurance company does is follow the guidelines that were set forth by the employer. Mistakes happen and claims may get processed incorrectly but all you have to do is call the insurance company if you notice something is wrong and they'll correct it. Whether or not something is going to be covered is determined by the employer offering the plan. If an employer sits down and says "cover everything and we'll pay for it all" then that's what insurance companies do. If they come in and say "we don't want to cover chiropractic care, massage therapy, speech therapy, acupuncture, or bariatric surgery and we're going to split the cost of what we are covering with our employees" then that's what the insurance companies will offer and enforce.

/tangent

--------quote fail-------------
Sorry that it hurts your feelings, as someone who makes her living billing insurance companies that is exactly my experience. It took BCBS a full 2 years to properly reimburse for services rendered and billed appropriately. Their policies of rejecting billing or partial reimbursement have severely hurt my our agency's ability to service the special needs kids that we work with. Those policies basically bankrupt our company (we are back on track now, but still owed a good amount). And it's really easy to say that we should bill the families and they should be reimbursed by the insurance company but the families can't afford that, even very well resourced families can't afford that.

skootnshoot25 · December 2014

etoille said:

skootnshoot25 said:

etoille said:

skootnshoot25 said:

I work for a disability provider and worked in STD as well as have counseled employees on the benefit. Each policy is different but as a rule there is a pre existing period which means if within the time before the policy effective date (usually 3, 6, or 12 months) you have had diagnosis or treatment for the condition you are going out of work for, pregnancy included, the claim will not be paid. The waiting period is the time the policy has to be effective before a claim will be paid. And some policies have a look back period, usually the first year, and if you file a claim during that time they will look at the pre ex period to see if you were seen for that condition. Basically an insurance company is not going to sell you a policy that you will use in the first year for an existing condition. They wouldn't stay in business. It sucks if you are not covered for this reason, but it's why if you are trying to get pregnant, so many articles advise you to research your disability policy and get insured before you need it. Of course if you aren't/weren't trying then it might not have been on your mind way back then.

Side note - I did actually confirm no prexisting/pay in for my policy. It might be something that's more characteristic of employer provided/paid coverage but this is the only experience I've had with two-three different employers at this point.
You may be right - I only have experience with my own company and the various policies they offer. It is good to confirm those items like you did. Even working in the business it takes time to understand everything so it's harder when you aren't in it every day.

Yeah it's insanity. I sat down and devoted a LOT of time to understanding this stuff after getting screwed on the allergy panel stuff. I think that's why I get so pissed off about it - like I am UBER proactive (hell we registered this second baby for day care in June today and had a conversation about kindergarten for the 1.5 year old, I've already preregistered with the hospital and I had a realtor out to the house 3 days before my induction to discuss putting the house on the market in a year) so I am not like the average consumer who is blissfully unaware of stuff.

I take the time to educate myself and really work through this shit so it's REALLY aggravating for me to feel like I am dealing with folks who should know more than I do in order to confirm this shit .....but like they don't. Most of the time they just effing don't. So frustrating.

I totally understand. After months of researching my health insurance before and during my pregnancy, I (politely) lost it on them when the billed me more for my midwife than they would have for an OB/GYN. I ended up submitting an appeal and won. It wasn't about the money for this, but I 1) don't want issues when I deliver then baby and it really costs money and 2) think it's ridiculous that I have a higher understanding of insurance than most and they still managed to sneak something by me - the policy should be consumer friendly, period.

chaysefaith · December 2014

Mostly I get annoyed when people blame insurance companies for shit they have no control over, like in my example above, the covered benefits.

I don't know what happens at other insurance companies but the one I work for also wouldn't be able to help with eligibility issues (unless it's for a private plan) and those are all handled through the employer.

If someone needs something preapproved and it's not done, 100% of the time it's because the doctor either 1) failed to submit for approval early enough or 2) failed to show proof of medical necessity, which is almost always a matter of the doctor didn't submit ANYTHING except for a request for an approval. Also, something requiring a preapproval is soemthing that's written in when companies decide on benefits.

Maybe the company I work for is just different from other companies, though. I have insurance through my H with Aetna and I don't like the way they do things. I needed a copy of my insurance card faxed to quest once and they refused. They also send one EOB for a series of claims instead of an EOB for each claim, which I don't like.

I also have an insiders look at things so I'm probably way more understanding when things aren't done than most people would be.

Anyway. I hate talking about health insurance since I do it all day, so that's all I'm going to say about it.

ruemorgan · December 2014

saltyfins said:
I'm in the same boat. When I started my job in October 2013 (also enrollment period) I did not sign up for std. I honestly had no idea what std was for or that it covered maternity leave.

I found out I was pregnant in July 2014, and signed up for std in October 2014 when open enrollment came around again. It will not cover this pregnancy because I was already pregnant when I signed up. I knew that it wouldn't be covered but I will have it for the next pregnancy (assuming it happens again while I still have this job.) That's just how it works and I wasn't upset when they told me I wouldn't be covered this time.

I just wish I had signed up for it when I was hired. They would pay me 60% of my salary for the 12 weeks I'm on leave. It really stings knowing that I'm missing out on that and I'll be making $0 for 12 weeks but it's my fault for not signing up last year.

Quote box--
Yeah, my gut says I just gotta suck this one up. I did enroll for STD so atleast I will have that for the next kid as well. I couldnt call tonight because I ended up working too late, but on the other hand my boss at my FT job said I could come back a week or two early and work in the office, my PT job said their company doesnt require a drs approval to return to work and can come back as soon as I like, and my husband works in an office alone so he can watch the baby at work atleast for a few weeks until we bounce back so im just thankful we have options. It really does suck. But hey, now we know!

ruemorgan · December 2014

@etoille‌ whaaaat? I cant believe that would happen. Are you still with the same company? It really goes to show you need to keep a record of EVERYTHING.

rita213 · December 2014

There is also no such thing as a pre existing condition limiting from insurance coverage as of 2010 with the passing of the affordable care act. But as most have said most STD do require to have a year before paying out that is standard.

colleen4019 · December 2014

Sorry what does ftfy mean?

chaysefaith · December 2014

etoille said:

chaysefaith said:

Mostly I get annoyed when people blame insurance companies for shit they have no control over, like in my example above, the covered benefits.

I don't know what happens at other insurance companies but the one I work for also wouldn't be able to help with eligibility issues (unless it's for a private plan) and those are all handled through the employer.

If someone needs something preapproved and it's not done, 100% of the time it's because the doctor either 1) failed to submit for approval early enough or 2) failed to show proof of medical necessity, which is almost always a matter of the doctor didn't submit ANYTHING except for a request for an approval. Also, something requiring a preapproval is soemthing that's written in when companies decide on benefits.

Maybe the company I work for is just different from other companies, though. I have insurance through my H with Aetna and I don't like the way they do things. I needed a copy of my insurance card faxed to quest once and they refused. They also send one EOB for a series of claims instead of an EOB for each claim, which I don't like.

I also have an insiders look at things so I'm probably way more understanding when things aren't done than most people would be.

Anyway. I hate talking about health insurance since I do it all day, so that's all I'm going to say about it.

Yeah sorry. Calling bullshit on the 100% of the time. You can't be all like "human error means we totes get a pass on telling people incorrect information" and then be like "100% of the time it's not our fault."

Which is it? I'm sorry this is the PRECISE reason people find dealing with insurance companies to be a nightmare.

BTW my preapprovals for the anatomy scan they denied were submitted a MONTH in advance and submitting it in advance for approval was a clinic level procedure (my insurance didn't require it) - they (the insurance) PRE APPROVED the fucking thing and still denied it later.

So there you go. Not 100%.

I'm legit done after this. What I said was being quoted incorrect information or having a claim processed incorrectly is human error. Not getting something preapproved or not having something preapproved by the time you're scheduled to have it done is because of clinical information not being received or not enough clinical information sent in.

A preapproval that's not required does take more time than one that is required (we quote 30 days) because they're not a priority since they are NOT required. All that does is establish proof of medical necessity should there be an issue getting a claim processed, which it sounds like you had and SHOULD have been easy to resolve with your preapproval.

Dude, maybe you have such shitty experiences because your attitude fucking sucks. Again, I never said mistakes don't happen, I flat out said that they do. I also said that I get defensive (what I really said was "it hurts my feels") when people flip their shit about how much insurance companies suck when the issue they're upset about is nothing the insurance company can control.

The only reason I even brought any of this up was because someone mentioned how much insurance companies suck. Like I said, I'm done talking about it. Sorry you've had such shitty experiences with every.single.example I gave, etoille.

mangomimosa · December 2014

The way mine works -- and this was made abundantly clear to me when I got the job in Oct 2013 -- is that you get automatically approved for STD if you enroll immediately upon being hired, but almost no one gets approved for STD if they try to enroll during open enrollment later on (they will find anything to use as a pre-existing condition). Also, we were told it has to be active for 12 months before you can use it. So I knew, in Oct '13, that if we were planning a baby in 2015, I had to sign up for it right away. And that's what I did.

What's shitty about mine is that they cover 8 wks vaginal / 12 wks c-section BUT you cannot draw any STD pay until you've used all your PTO and waited 1-wk "wash out". So if I have a vaginal birth, I use my 6 weeks PTO, wait 1 wk "wash-out" and then I get only 1 week of STD pay ($500). I think it's just barely worth it from what I've paid for the STD insurance so far. (Of course I have the "peace of mind" that if I need to use it for another reason, it'll be there.)

Anyway --point is, I did everything right and it's still a fucking joke.

colleen4019 · December 2014

Thanks @etoille‌ I understood it to be 'fuck that, fuck yourself' which really didn't seem to fit with the current usage.

ruemorgan · December 2014

colleen4019 said:
Thanks @etoille‌ I understood it to be 'fuck that, fuck yourself' which really didn't seem to fit with the current usage.

Bahaha, I like your version on FTFY.

colleen4019 · December 2014

ruemorgan said:

colleen4019 said:
Thanks @etoille‌ I understood it to be 'fuck that, fuck yourself' which really didn't seem to fit with the current usage.
Bahaha, I like your version on FTFY.

Lol! I even asked my hubby who said 'f that f yourself' and I thought 'man, even for the bump that's pretty harsh...?'

mwerren · December 2014

Definitely take the matter up with HR. Also, does your state offer any type of assistance? I know here in California we have Family Medical Leave Act coverage. Also, I seem to recall in the first post you mentioned that you thought you did sign up in 2013?? If all else fails, you can contact the labor board. Sorry for this sucky situation. I hope you are able to get a resolution that's fair to you

mandi195 · December 2014

ruemorgan said:

I assume they were offered other options because they didn't tell the people they were pregnant.
I was asked if I was pregnant, and they were NOT asked if they were pregnant. I feel like that question should be universal if you will penalize someone based on the answer. It sucks to see that I probably have no chance at changing the situation, but im atleast glad to have gotten a more practical view of the situation and other STD policies. Thanks for all the input. Im still going to call tonight and see what happens.

Is it possible that they weren't asked that question because they've already been paying for STD for a year? Just a thought (and if not, then it could have been due to speaking with different reps)

2Swanns · December 2014

I'm so paranoid after reading this thread. I started my job in April and signed up for STD on Day 1. I was told I was covered as of May 1. I got pregnant in June and I told my HR dept in September/October. As far as I know, I'm covered and will get 67% of my pay after two weeks (unpaid or using PTO) for 10 weeks.

Sounds all well and good, but my workplace is a little scattered and I wouldn't be surprised if I went out on maternity and they came back and said, "Oh, well...you're actually NOT covered!" I'm calling them tomorrow.

ruemorgan · December 2014

mandi195 said:

ruemorgan said:

TikTak said:
I assume they were offered other options because they didn't tell the people they were pregnant.
I was asked if I was pregnant, and they were NOT asked if they were pregnant. I feel like that question should be universal if you will penalize someone based on the answer.

It sucks to see that I probably have no chance at changing the situation, but im atleast glad to have gotten a more practical view of the situation and other STD policies. Thanks for all the input. Im still going to call tonight and see what happens.

Is it possible that they weren't asked that question because they've already been paying for STD for a year? Just a thought (and if not, then it could have been due to speaking with different reps)

Nope. One has worked with the company for 6 months and the other has worked there for 3 weeks

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