Dive Insurance...What is really covered?

[StSomewhere]

I would like to hear DAN's comments on the case.

Which DAN? The insurance company or the research outfit? They are different entities.

 

[Christi]

A buddy of mine had as experience with Dive Safe, and has switched back to Dan. Dan helped him when he was not a memeber and Dive Safe was not available for a phone consultation. Dan also contacted the Hospital before we got there, and followed up. All for someone who was not a member.

While I can not comment on the specifics of Chritis friend, I hope DAN will comment.

Christ, which facilty did your friend go too? The DAN one or the other one?

There is not a DAN facility or the other one. They are all affiliated with DAN. But I took him to Meditur which is the smaller much more private facility at San Miguel hospital. They treated me when I had my DCS and he is very thorough and truly has the patient's best interest in mind. He does not put everyone that walks in the door into the chamber. He has been practicing Hyperbaric medicine here for 23 years. He also has a facility in Playa del Carmen. In fact this Dr. is a DAN Instructor!

Cozumel does have a higher rate if DCS incidents than most places...we have more divers in the water on any given day than other destinations.

 

[Jason B]

Which policy did he have...standard, master, or preferred? The standard plan pays $45000 lifetime max, where as the master pays $125000 lifetime max, and the preferred pays $250000 per occurance. Just curious as I've heard it can cost up to $10,000 per chamber ride.
Oh, I hope your friend gets this all resolved and recovers 100%.

Jason

 

[DA Aquamaster]

Which DAN? The insurance company or the research outfit? They are different entities.

Sort of but not really.

Divers Alert Network (DAN) is a 501(c)(3) non-profit medical and research organization while DAN Services, Inc. is a for-profit, wholly-owned subsidiary of Divers Alert Network. So while DAN does not directly profit from the insurance sales, they own the company that does.

DAN Services also does not handle their claims management directly as that task is contracted out to another company. So the quality of the service and the tendency to accept or deny claims can vary depending on the company in use at the time. What this means is that the person approving your insurance claim may not know beans about diving medicine and, as we discovered, a recommendation for treatment from a DAN physician does not equate to pre-authorization for treatment from either DAN Services or the company that manages their claims.

Personally, I think the impression created by DAN operating as a non-profit medical and research dedicated to dive medicine and then using their name in association with a wholly DAN owned for profit insurance company with very HMO style claim approval policies amounts to deceptive advertising.

While DAN may not have much to do with day to day operations of DAN Services or with how the claims are handled, I suspect a large enough quantity of informative letters of complaint to DAN would eventually have an impact on how the insurance program under DAN Services is ultimatlety managed as they are in the end severely damaging DAN's reputation.

DAN is dedicated to dive safety and I feel that that philospohy should extend to any DAN owned medical insurance company. There should be no restriction on payment for treatment (within the maximum policy limits) assuming the treatment is prescribed by a physician for a dive accident or other covered accident.

If the resulting costs of adhearing to that philosophy cannot be covered by premiums, then raise the premiums instead of compromising the service or restricting the treatment of DAN members with dive injuries.

If the costs of adhearing to that policy cut into profits, I have a problem with that as I don't think the primary goal of for profit wholly owned subidiaries of 501(c)(3) non profits, should be making a profit.

 

[DA Aquamaster]

Cozumel particularly because DAN claims that we have the highest risk...OF COURSE we have more cases of DCS here...we have more divers in the water on any given day than other destinations.

If the actuaries at DAN Insurance have concerns with the safety record and treatment costs at Cozumel, the automatic bean counter answer is to tighten up on claim approval.

The right answer however would be to assess the situation and have DAN do one of the things DAN does best - teach. If DAN Insurance is concerned, they could have DAN do research and if the need truly exists, have DAN do instruction with local operators and/or destination divers to proactively work toward reducing the number of dive accidents.

 

[Jason B]

Someting of interest I found via google....

Dive insurance policies are what's called coinsurance, meaning they're designed to reimburse you after the fact for covered expenses. That means you usually have to pay the hospital or chamber yourself, seek reimbursement from your primary health insurer (if you have one), and then from the dive insurer. To avoid any potential delay in treatment or evacuation, you should have a roomy credit card at your disposal.

Some travel assistance companies like AssistAmerica will guarantee payment for at least your admission and emergency treatment. DiveAssure claims to be the only insurer that regularly pays the provider directly and seeks reimbursement from your primary health insurer later. Others, DAN for one, will also do so on a case-by-case emergency basis, but they aren't obligated to under their policies. As always, read that fine print.

I think I'll go with DiveAssure when my DAN plan is due up again...

Jason

 

[HammerNoMore]

So when did the insurance company become the treating physician as well?

If you read your DAN handbook which goes into details about the plan, on page 23 is the defintion of Medically Necissary. The first paragraph clearly spells out that the insurance company (United States Life, not DAN) gets to make that call.

I think there is more than meets the eye here. It's not that I suspect Christi would mislead us in any way, but that I doubt she, or even her friend with the hit knows the entire story. What strikes me as suspicious is that the policy clearly states that up to 7 chamber rides are covered and that chamber rides after the seventh must be approved.

I do not undersand why US Life would even be consulted, i.e. why the treatments would not just be given and then turned into the insurance company later for reinbursement as is the common practice.

I also think the profile could be relevant here. Where was this dive, Punta Sur, Maricibo? If so it is likely that none of the treatment is covered.

Insurance companies are supposed to try to avoid paying claims. If they don't the doctors and drug companies would try to rape both them and their patients even more than they already do. However, it is probably the most regulated industry in existance. Yes, there are some bad apples but for the most part if they are legally required to pay the expenses they will, though it might require a little pushing. If they are not there there is no reason for them to.

But, alas, insurance companies are easy targets for so much speculation...

James

 

[doole]

Insurance in general is a scam.

I'll always remember a life insurance salesman trying to ply my Dad. He said: " It's a win-win scenario; on one hand you're living your life and paying just a small pittance for protection and on the other, your loved ones are protected."

Dad said, "Sounds like a lose-lose scenario to me. On the one hand it costs me money and on the other - I'm dead."

 

[StSomewhere]

Sort of but not really.

We really aren't disagreeing.

DAN (the medical/hyperbaric research outfit) is who you call for advice when DCS is suspected. They are the equivalent of the lone shareholder of DAN Insurance (though I've read the previous DAN president tried to hijack the lucrative insurance business for his own benefit). But like almost all insurance outfits, DAN insurance is reinsured and administered by other companies and is run/adminsitered like any other insurance business.

The things to understand is that you can call DAN the non-profit for hyperbaric medical advice no matter which dive insurance you have. It just so happens DAN the non-profit is funded largely through DAN Insurance (the lucrative insurance operation). I know people have some sort of sworn allegiance to DAN, I just want to make sure they understand that the two entities are effectively separate and have VERY different goals.

IMO, DAN Insurance trades off the goodwill generated by DAN the nonprofit. Of course as we see here, DAN the nonprofit may also suffer from the negative goodwill generated by DAN Insurance. That's the tradeoff for saving money on Cozumel DCS treatments. They can't have it both ways.

Frankly (and I realize I'll take crap for saying this) the whole discussion has made me rethink DAN Insurance and the safety of diving Cozumel...

 

[Christi]

...I also think the profile could be relevant here. Where was this dive, Punta Sur, Maricibo? If so it is likely that none of the treatment is covered...
James

It was his very first dive, 70 feet max, 42 minutes (which included the safety stop). Nothing crazy about his profile.