Oh, You Gotta Have Friends!

This is most certainly a culture awash in mixed messages.  On one hand, we are told we need to check with our doctor every time we decide to lose a pound or two or go for a walk, while on the other hand, we are encouraged to trade stocks on our own (!?) or undertake a massive plumbing and tiling project with no more skill or experience than a Lowe’s card and a new trowel can buy.  We can stay home in our pj’s and pursue an advanced business degree without ever going near a classroom or braving a face-to-face discussion,  but we need to eat out in public every night, smiling and joking and spending wads of cash with our friends, who  happen to be just as smiley and skinny, too,  even as they eat mounds of cheese-covered fries.  How we make these friends as we stay home with our alarm systems and do just about everything else alone or on our own is never made clear.

We are targeted and test marketed and analyzed and demographic-ed within an inch of our lives every day.  Who benefits?  Good question.

This brings us to the insurance agent issue.  We are told all the time that agents are not necessary at best, dangerous self-dealing predators at worst.  Really?  Even used car dealers have better press! As we have all figured out lately, however,  insurance is a complex and emotion-laden purchase, especially health insurance.  It’s a good idea to take advantage of the knowledge and experience of a professional when considering what kind of plan to buy.  And it is also very handy to have an agent on your side when things go wrong.  And things do indeed go wrong.

Consider this story.   An Arizona couple had a small business and a decent group health plan. When the plan had been in place for more than two years, the wife, Carole, called her agent with some distressing news.  She had submitted for pre-approval for an expensive medication ($15,000 per treatment) and been denied.  The agent talked the situation over with Carole and did a bit of homework on his own.  The agent found that the treatment was expensive but not experimental or controversial in any way – in fact, Mayo and two other fine providers recommended it.  It was deemed medically necessary for Carole’s treatment by her physician.

The agent figured it was just an oversight on the health carrier’s part; Carole submitted an appeal.  The appeal was promptly denied.  In the interim, Carole’s health deteriorated and she was told she might not survive without the expensive but denied protocol.

The agent decided to keep fighting.  He secured a HIPPA release from Carole and went all the way to the COB of the insurance company.  When he called, he cited the latest research on the management of Carole’s illness and the best new treatment for her condition.  It worked.  The treatment was approved; Carole recovered and, after several years,  she and her husband are still running their small business.

What happened?  Why was the original claim denied?  Keep in mind that this was a reputable, major carrier, with quality health insurance plans.  It turns out that the insurance company sent the first request to a doctor who had no qualifications in this specialty.  Further, he used outdated information when making his decision.  He determined that the treatment was not efficacious in Carole’s case – which was flat-out wrong.

Now, the insurance company did the right thing when confronted with new information.  And that’s just the point, here.  Carole’s agent, with whom she had a long-term professional relationship, went to bat for her.  Because he knew her personally.  Because he had helped the couple select that plan.  Because his own reputation was on the line and he wanted to keep them as clients, to be sure.  But that’s a very small part of this story.  It was, it is, the personal connection that made all the difference. Carole was ill and getting worse, while her husband, worried about his wife and fighting to keep his business open, did not know what to do.  But their agent knew what needed to be done.  And he went to work.  And no anonymous call center, bargain brand temp worker or disembodied virtual agent is ever going to replace that kind of service or commitment. Not ever.


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