Check your stop-gap coverage/out of area!

[dersequim]

Nancy was injured in a fall in Ca in March. It required surgery and 2wks in hospital. When we returned to Wa., I started the usual discussions with the Ins. Co about payments. During one rather firm/long discussion regarding the disbursments of our deductable, $1500, and when the $3000 Stop-Gap Provision would kick-in. I was informed that the S-G ceiling does not apply OUT-OF-AREA????? We would be resposible for 20% of ALL COSTS of the Ca billings!!! I checked my policy and there it was. I called my Agent who was SHOCKED. We had quite a bit of discussion about coverage while traveling before I changed to Regence BlueShild from my former coverage.
They have assigned me my "Personal" benefits co-ordinator due to my persistant auditing of their payments and assignments to us. So far, as of today, she has adjusted the hospital charges in Ca , saving me $700 and a couple local billings for about $200.

[Bowie]

Sorry about Nancy's injury--hope that she has recovered completely by now. As to the suggestion you make--a very good point. Wish that your agent had known as it might have saved some hassles for you. So what is the purpose of the stop-gap and under what circumstances would you be allowed to use it?? Hope that it is all eventually sorted out to your satisfaction. In a similar vein, if anyone is planning to leave the country, be sure that you know what your insurance will and will not cover in the place you are visiting. Also, consider purchasing an additional policy which will repatriate you in case you do not wish to use the local hospital services. We had an experience in the UK which emphasized the importance of your point and the need for the purchase we suggest. Long story short, we were billed L12,000 ($18,000!!) for hospitalization which should have been covered by our out of area BUT we were so FAR out of area that the insurance company thought they could negate the entire claim. A year of wrangling ensued until we provided a phone company printout proving that we had consulted with our PCP throughout the entire ordeal and the insurance company was forced to pay. Given a choice, we would have brought Pat home--and a repatriation policy would have accomplished that. Unfortunately since we were living there it never entered our heads (or the company's either!) that such a thing would be needed! Here's to HEALTHY travels...

[dersequim]

Thanks for your concerns. Stop-gap or out of pocket expense limit is the total amount above your deductible that you can be charged per year. It mostly applies to the 20% on an 80-20% policy.

[Northstar]

Thanks for the heads up post. Something to think about. Happyrving......

[DHenry]

Great post, it gives me more to think about when I want to take a long trip.

[Treecounter]

We also carry Blue Cross ins. Several years ago Glub broke her back in Mexico. She spent 10 days in the Hospital in Mazatlan. With X rays Cat scans etc. Bill was $1500. They paid it all. This was before she was on Medicare.(which will not pay out of country) It took a year to get the DR. bill paid as he didn't itemize. When we got back to Mazatlan he made a itemized bill and the reimbursed us the $600. She had excellent care while in the hospital there. It was Sharp Hospital.