Insurance refused on CPAP shipped to Canada: help please

[MichaelWalker]

Hi all.

New to the forum but have been lurking the past few days soaking up all the great information here. Seems like a very helpful and cohesive community.

I live in Victoria, British Columbia, Canada and have recently been dx with apnea (75 AHIs/hr). I'm sure I've had it for most of my adult life but have only recently followed this path to getting it checked out.

Subsequently I've been trying to get reasonable rates for the machine and supplies here in BC including required software, a good nose pillow mask, backup battery, etc. Seems everywhere I've called the prices are just exorbitant compared to cpap.com (eg: $1750CAN/$1535US for the IntelliPAP auto at sleepapneastore.ca compared to $650CAN/$595US at cpap.com - an $1100 difference, and thats for the machine with humidifier only). I was even quoted $800CAN *just* for the reader and software on an M series Auto! I understand the (supposed) support differences between these sources but with software I'll be doing the same things at home anyway. All the price differences are completely outrageous in my eyes.

Unfortunately, I just got off the phone with my supplemental insurance company here in BC (Pacific Blue Cross) and they *WILL NOT* cover the 80% cost if I source the equipment from anywhere other than British Columbia. I simply can't believe that to be the case, but I had her repeat it just in case.

I can't afford the estimated $1100US out of pocket without my insurance covering 80% so I think I'm stuck. If I go the BC route, my 20% portion looks to be around $650ish as opposed to the $230ish I'd pay at cpap.com - let alone the thousands in difference for my insurance company itself!

Long story short (too late, sorry!), have any of you fought with your insurance company here in Canada and won coverage sourcing from cpap.com or elsewhere in the states? Is it worth the time or effort to go up the chain and see if I can help *THEM* and me save thousands of dollars? Anyone had any experience with Pacific Blue Cross in particular?

Any insight you might provide would be extremely helpful. Thank you.

Michael

[Hawthorne]

No help here! I'm in Ontario and could not convince my extended health (different company than yours) to cover their share of a machine purchased online from cpap.com. They would only cover their %, at a much higher cost to them and to me, if I bought in Canada!

It's ridiculous!

If you have the time and energy you could try and get them to see the light.

I think some in Canada have succeeded in getting their extended health to see "the light" and save everyone money! Some of those people may reply to your post.

[Hose_Head]

Long story short (too late, sorry!), have any of you fought with your insurance company here in Canada and won coverage sourcing from cpap.com or elsewhere in the states? Is it worth the time or effort to go up the chain and see if I can help *THEM* and me save thousands of dollars? Anyone had any experience with Pacific Blue Cross in particular?
Michael

I live in Toronto. My supplementary insurer is Great West Life. They will cover 100% of specified items such as masks and hoses regardless of where they are purchased (i.e. online purchases are OK). However, they do not cover the cost of shipping. I don't know why because an online purchase will save THEM lots of money while saving me just a few bucks in shipping charges.

I've not tried to get them to cover the cost of an xpap when purchased online, but I have been wondering about it. I feel a need to get a backup machine and I know that Ontario's ADP program won't pay for it.

Have you tried escalating your request with your insurer? Often, the grunts on the telephone lines are poorly trained. As well, is there a complaint mechanism with your insurer that you could try?

Can you change insurers?

Ask if they will pay for used equipment that is purchased locally. There are deals out there on seldom-used cpaps (check kijiji and craig's list - don't go by the listed asking price)

[Julie]

Manulife covers all my stuff (as G. West did previously), through my ex's company insce.

[feeling_better]

There are others here who experience this seemingly insane stand by the insurance company. It is very similar in the USA. To make some sense out of this, this is what I speculate is actually happening. The insurance company actually get the product from the manufacturer under some huge discount (as part of their negotiated volume buying arrangement), but both the manufacturer and the insurance company agree to disclose the list price only.

Taking your case numbers as a sample, for example, your insurance company says it costs $1535US, and would cover 80%, requiring you to pay, 20% = $307US. What may be actually happening is that they get the equipment from the manufacturer at a lower price than even CPAP.com can buy. If we assume that cpap.com makes a 10% profit, then cpap.com buys it for 90% of $595US = $535US. So if the above is true, the insurance company might be getting it for say, $450US. So they actually only pay you (=insurance company reimbursement, or their cost for this) about $450-$307 = $143US. But if they allow you to buy from cpap.com, they will have to reimburse you 80% of $595 = $480!! A very big increase for them.

I have no data to support the above procedure by insurance company, it is my guess. Such a procedure might seem even illegal, but I think it is allowed under our business practices as normal.

[scotty]

When I call customer service anywhere for information, I usually also try to find information on from their website, on the web in general, and any information I already have at home about my account/plan. CS is a great resource, but often, in my experience, they're just looking up stuff when you ask, and there might be more to it than they're aware of. What does your coverage information say? You would have gotten that when you enrolled, and likely have gotten it annually since then. Is there something like Ontario's ADP that might help? I have no idea if ADP would've covered mine, anyway. You might also want to check out of you have a flexible spending account where you work or if there's someone in your family whose flexible spending account covers you, too.

It bites that it would be cheaper if your insurance company would cover ordering from the US, but once you determine that it's absolutely NOT an option, then try not to dwell on it too much. If they did cover it, your rates might be higher since they might figure that dealing with foreign suppliers is riskier, they can't monitor their quality as well, or because they'd be dealing with suppliers who are not certified or authorized by whatever government agency certifies suppliers of medical devices.

I do sympathize, though. Four years ago in Ontario I just had what ADP covered, the rest was out of pocket (no supplemental insurance). Earlier this month I bought a new machine and mask here in the states from cpap.com totally on my own -- no insurance, nothing. Even factoring exchange rates, I paid less on my own here in the states than I did with ADP in Ontario. However as a Canadian and American and having lived in both countries, I love both and love living in either, but there's always trade offs. Living in Canada, this was one of them.

Anyway, hope you find out (with perseverance) that they will cover it. And, if not, I hope that after you get your machine, find your life so much better, that you'll just be glad that you finally got one. Either way, you could probably recoup some of the "loss" as a medical tax deduction later.

[Guest]

NEWSFLASH: Things have different costs around the world! For whatever reason and whether it's "fair" or not. Companies that ship where they're not allowed to only make the matter worse.

[MichaelWalker]

NEWSFLASH: Things have different costs around the world! For whatever reason and whether it's "fair" or not.

Gee, you think? If we were talking about the difference in currency here (and some markup for the extra shipping, etc), well that of course I have no problem with. We're not. We're talking about triple the pricing: not from the manufacturer but from the re-sellers here. Thats a HUGE, massive markup. Basically, however, that's not the issue. The issue is the insurance company. Anyone can "try" to sell something for whatever they want, I've no problem with that either. What I do have a problem with is if a competitor sells something for less and *I'm not allowed to buy it* by writ of my insurance. *That* is the problem, not just for me personally, but for the whole economy! People talk about how out of control health care costs are... well, this is a perfect example of WHY THAT IS.

Companies that ship where they're not allowed to only make the matter worse.

I have no idea what that even means. Who says online retailers ship anything where they're "not allowed"? Thats nonsense. They can and, indeed, do ship to Canada all the time and vice versa. It's called Free Trade.

[MichaelWalker]

What does your coverage information say? You would have gotten that when you enrolled, and likely have gotten it annually since then. Is there something like Ontario's ADP that might help? I have no idea if ADP would've covered mine, anyway. You might also want to check out of you have a flexible spending account where you work or if there's someone in your family whose flexible spending account covers you, too.

Thanks for that insight... indeed, I'll check the fine print of my coverage instead of relying solely on a CS rep. I looked up the web site of PBC and they have only general information on what's covered, not specific amounts or policy so I'll try to dig out the actual policy and see what I can find. Again, thanks for that tip.

Earlier this month I bought a new machine and mask here in the states from cpap.com totally on my own -- no insurance, nothing. Even factoring exchange rates, I paid less on my own here in the states than I did with ADP in Ontario. However as a Canadian and American and having lived in both countries, I love both and love living in either, but there's always trade offs. Living in Canada, this was one of them.

I too am an American who has transplanted to Canada (met my wife here 21 years ago). This situation certainly has nothing to do with the greatness of one country over another or anything like. Its specifically about health care costs imposed by an insurance company... thats universal no matter what country we live in unfortunately. I too am contemplating purchasing out of pocket from cpap.com since the price difference will be close to nil.

Anyway, hope you find out (with perseverance) that they will cover it. And, if not, I hope that after you get your machine, find your life so much better, that you'll just be glad that you finally got one. Either way, you could probably recoup some of the "loss" as a medical tax deduction later.

Thank you Scotty, I very much appreciate those wishes. I too hope the quality of my life markedly improves once I start "treatment". And indeed, at least the tax deduction will be something!

[MichaelWalker]

There are others here who experience this seemingly insane stand by the insurance company. It is very similar in the USA. To make some sense out of this, this is what I speculate is actually happening...

I bet you are dead on. There simply has to be some behind the scenes structure thats in place supporting what, on the surface, looks like a complete "lose" for everyone. Thanks for that insight.

[MichaelWalker]

Have you tried escalating your request with your insurer? Often, the grunts on the telephone lines are poorly trained. As well, is there a complaint mechanism with your insurer that you could try?

Can you change insurers?

Ask if they will pay for used equipment that is purchased locally. There are deals out there on seldom-used cpaps (check kijiji and craig's list - don't go by the listed asking price)

Thank you for those ideas. After I look up the exact details of my policy I may indeed try to escalate with my insurer if still needed. If not out of princaple more than anything else. Maybe a letter to the president of the company if that doesn't lead anywhere. I'm not sure about a complaint mechanism but I'll look into that as well.

I can't change insurers as I am part of a group plan through my work. As a teacher our extended coverage is chosen by the union. That may be another avenue, however, now that you made me think of it. I wonder how many others in our large group of insureds have faced the same issues? A call to the union may not hurt.

Thanks also for the tip on used equipment... I'm a little wary on buying used medical equipment, but I guess this instance isn't so critical. If it stops working in the middle of the night I'll certainly not die thankfully! Thanks again for the insight.

[billbolton]

Its specifically about health care costs imposed by an insurance company... thats universal no matter what country we live in unfortunately.

Actually its not "universal", it is something fairly specific to the way that the Heatlhcare systems work in the US and Canada.

Cheers,

Bill

[spitintheocean]

In all likelihood, your Insurance company is only acting as an administrator for the plan purchased through your employer. Actual costs get passed back directly to your employer. If you believe that your insurer is deliberately choosing to deny the less expensive procurement option, the consequences of that decision primarily fall to the employer or union as the case may be. You may find that contacting your internal plan administrator and explaining how you want to save the company 80% of the cost differential but their agent will not allow it, may prove sufficient impetus for real power to be wielded against the Insurance company's intransigence. Suddenly they won't be intimidating a single claimant but instead be faced with an irate policy holder curious to discover what other needless costs are adversely impacting the Corporate bottom line.

[Henry M.]

I think there are several very valid points but a few items that have not been mentioned. I know that when I purchased my CPAP device the homecare provider that I purchased through in Ontario spent several hours of their therapists time educating me on obstructive sleep apnea, fitting my mask, teaching me how to operate my CPAP machine, trouble shooting any problems I faced, downloaded my device information to send to the Dr. and even changing my prescription following a re-visit to a local sleep lab. I wonder if you purchase a unit from an internet provider or someone who is not local if you can expect to get this same kind of service. I am sure it is not cheap for these providers to staff their offices with trained healthcare professionals. I know since this is my health I would like to know that I am being looked after by a trained healthcare professional and realize that there is a cost for the excellent service I have received.

I also had the unfortunate issue where my device failed and I was given a brand new replacement device the same day from the local dealer. A few cautions to beware of when you purchase in the US versus Canada, I discovered that the warranty is not the same in the US for my device as in Canada and I get 1 extra year of warranty. I also know that all products sold in Canada is required to be approved by a regulatory body called Health Canada and I doubt that a US based internet company is selling Health Canada approved equipment. I have also pondered if there was a recall of product how or if you would ever be notified by a US based internet company and if you were what you would have to do to manage the situation? This may seem way out there but something I thought about as I was typing this note. Many local companies also offer a mask satisfaction promise, this means if your mask does not fit or causes you problems within the first 30 days you can return and get another mask at no cost, I highly doubt this would be available from an internet company.

I do believe if you are buying a replacement product that the price should not necessarily be the same price as a first time purchase because no service is required but if down the road you require service then just as in any other industry or business you should be expected to pay for it.

I felt compelled to be the devils advocate here because I have purchased over the internet and it was not a pleasant experience when I had problems and I did not find the service or response appropriate.

So I will continue to buy local and I am willing to pay extra for the service and professional staff that comes with dealing with a homecare provider versus a box mover.

[Hose_Head]

I can't change insurers as I am part of a group plan through my work. As a teacher our extended coverage is chosen by the union. That may be another avenue, however, now that you made me think of it. I wonder how many others in our large group of insureds have faced the same issues? A call to the union may not hurt.

My insurance coverage comes through my employer and a collective agreement with my union. The working agreement provides a mechanism for appeal to a "joint benefits review committee" which hears appeals on denial of insurance coverage. Your union may have something similar to this. I highly recommend you discuss it with them.

Best of luck. Please keep us posted on your progress!