I subscribed to Strategic Resources Inc's insurance coverage from mid-2003 until March 2005 through my employer, Adecco. Last October, I underwent emergency surgery. I assumed that my surgery would be covered by SRC, because according to their policy, half of all in-network emergency inpatient services are covered up to $7500. In addition, according to their policy, 85% of anything over $7500 in inpatient expenses is covered per calendar year.
When I received my hospital bill totaling $40,000, I assumed that I would only be liable for about $8500 of my bill based on the percentages outlined in my policy. I was surprised to receive my adjusted statement from SRC stating that they were only paying for $2500 of my hospital expenses, and that I was liable for about $29,000 after deductions made by the hospital and the insignificant $2500 covered by SRC.
When I called SRC's 800 number, I was told by a customer service representative that the reason SRC would only cover a small portion of my expenses was because I had not reached the $7500 limit that would kick in the 85% coverage rate, even after $40,000 in hospital charges. She further explained that the only way for anyone to reach the $7500 limit would be to stay in the hospital for 11 days or more.
If there are limits to what percentages are covered by the policy they should be stated in plain English in the policy itself, including the loophole regarding an 11-day hospital stay. I should not have had to find out what's covered by the policy from a customer service representative after the fact. In addition, I've consulted with physicians who informed me that it is very rare for anyone to be hospitalized for 11 days, except in the case of a comatose condition. Thus, anyone with a hospitalization that lasts less than 11 days is out of luck, which must include most hospital stays.
The SRC policy is misleading, and not only that, it cheats its insureds out of catastrophic coverage with its 11-day hospital stay policy. Most policy holders would not be able to figure out from their policy that anything over $7500 is not covered outside of an 11-day hospital stay. And most insureds would assume that at $100 per month, they would receive catastrophic coverage at a rate better than $2500 for a $40,000 operation.
Regarding my situation, I now have to apply for charity benefits from Summit and hope that they will cover my bill. If not, I will have to file for bankruptcy. This defeats the purpose of paying $100 per month for health insurance. The policy written by Strateic Resource Company/Aetna is underhanded and misleading at best and dishonest at worst.
Diana
Oakland, California
U.S.A.
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