Question: Your employees health insurance allows them to choose from one

Your employees’ health insurance allows them to choose from one of three health maintenance organizations (HMOs). Once employees have selected an HMO, they must get all medical care (except for out-of-state emergency care) from the HMO. Employees receive a listing of the doctors and hospitals affiliated with each HMO when they join the company and pick an HMO and again each October when they have a one-month “open enrollment period” to change to another of the three HMOs if they choose. As Director of Employee Benefits, you’ve received an angry e-mail from Alvin Reineke. Alvin had just received a statement from his HMO stating that it would not pay for the costs of his hernia operation two months ago at St. Catherine’s Hospital in your city. Alvin is furious: one of the reasons he accepted a job with your company six months ago was its excellent health care coverage. He feels the company lied to him and should pay for his (rather large) hospital bill since the HMO refuses to do so. The HMO which Alvin had selected uses two hospitals, but not St. Catherine’s. When Alvin joined the company six months ago, he (like all new employees) received a thick booklet explaining the HMO options. Perhaps he did not take the time to read it carefully. But that’s not your fault. Alvin can change plans during the next open enrollment, but even if he switched to an HMO that included St. Catherine’s, that HMO wouldn’t pay for surgery performed before he joined that HMO. Write an e-mail message to Alvin giving him the bad news.
What tone should you use? Should you be sympathetic? Should you remind him that this is his own fault?
Is there any help you can give Alvin (e.g., information about credit-union short-term loans or even information about negotiating payment terms with the hospital)?
What can you do to make Alvin feel that the company has not lied to him?

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  • CreatedMarch 12, 2014
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