Former CSR: Was Following Federal Law To Help Someone The Right Thing To Do?
Jason writes in with an ethics question that's been bothering him for the past seven years: should he have helped a cancer-stricken patient who lost her family in the 9/11 attacks qualify for COBRA coverage? Sure, it sounds like a no-brainer, but it gives us a chance to see the sort of conflicts that gnaw at customer service representatives. Do they follow the rules and keep their jobs, or do the right thing and help the customer? Consider his conundrum, inside...
Jason writes:
This is something that has weighed heavily on my conscience for seven years, and I have to get it off my chest.Just after 9/11, I was working as a CSR for ProBusiness' (now owned by ADP) COBRA division. (COBRA is the Federal program that allows the recently unemployed/divorced/widowed/born to gain or retain employer benefits at a set cost.) As CSRs, our job was supposed to be answering COBRA questions and working as customer advocates in resolving COBRA issues. In reality, our job was to stonewall customers as much as possible. Except on one customer, where I was asked to do much more than that.
This one customer wanted to know why her COBRA claim was denied. There was a specific deadline that she had to file by, and she missed that deadline by one day. As I explained this to her, she began sobbing uncontrollably, explaining that she had lost her husband and daughter in the 9/11 attacks, and now was about to lose her coverage while enduring cancer treatment.
Working as her advocate, I pestered my managers for options. Their cynicism was apparent: they thought she sounded like a scam, so I should get rid of her. After pushing for answers for nearly ten minutes and thoroughly annoying my managers, they did admit she had a legal right to challenge the denial. However, informing the customer of her rights was not part of my job description and I would be disciplined and possibly fired if I did so. They were not willing to talk to the customer and inform her themselves. So it was either violate Federal law and keep my desperately needed job or do the right thing and risk not being able to make rent next month.
Here's what I decided to do: as per requirement, I returned to my customer and informed her, per the directions of multiple managers, there was nothing more that could be done, and ended the call. But, I wrote down her number, called her from a local gas station during my lunch break, and informed her of her rights and exactly what to do next. She cried some more, and finished with, "you saved my life. God bless you."
Eventually she did get her appeal and her coverage was retroactively approved. I never told anyone beyond my close friends what I did. I never reported ProBusiness for this violation, either. On one hand, I'm proud that I used my own judgment and did what I thought was right.
On the other hand, I feel terrible that I short-circuited company policy. You see, the policy was there for a reason. A significant portion of COBRA claims are denied because they are pure fraud. Fraudsters have no problem gaming the system to its absolute maximum to get what they want And when they do, the company's costs skyrocket. Giving fraudsters the same opportunities as legitimate customers equaled massive amounts of overhead and reduced the quality of service for customers, and put additional strain on our staff. Federal regulations do nearly nothing to protect providers against fraud, so companies have to figure it out for themselves.
Additionally, by using my case-by-case judgment, did I open up opportunities for lawsuits with "well I found out you did it for customer x and I have a better claim than she does, so why not me? Is it because I'm {specific minority}? I'm going to sue!"
So that's my dilemma. Did I stand up for a consumer, or was I hoodwinked by a fraudster? Did I stand up for consumer rights or did I naively do damage to the company?
- Jason
p.s.: I do want to be clear that if I did hurt the company, I don't feel that bad about it. ProBusiness was pure evil. Here are three examples:
1. Even if you pay your monthly premium, you coverage wouldn't officially activate until you attempted to use it. This was because claim activation a processing in 2001 was all done by paper and fax, by Federal regulation paper trail requirements. That's very labor intensive, so the company minimized the labor by not doing it until a customer actually needed it. Unfortunately, this meant that when Grandma went down to the pharmacy at 5:01pm on a Friday to get her diabetes medication, her claim would be denied and she would have to pay out of pocket or go without until we could fax an activation request to her provider Monday morning and wait 48-72 hours for it to turn around. When this happened (and it did - to me - twice) the official excuse to give to customers was, "hmm, I'm not quite sure why your claim wasn't activated. But, rest assured, we here at ProBusiness are right on top of it!"
2. Limiting call handle time is nothing new, but ProBusiness was especially pernicious about it. We had a policy where any customer with a record of long handle times was to be forwarded to a specific CSR. She was a real pitbull when it came to handling customers, and she would make them go away no matter what it took, including being psychologically abusive. The worst part is, she thoroughly enjoyed tearing customers a new one. She gave herself a gold star sticker every time she made a customer cry. She had a lot of gold stars. Ironically, she had a tiara on her computer monitor that said "Princess."
3. If QA flags you for something your supervisor told you to say, you get sacrificed. This is actually how I got fired after six months. Supervisors frequently gave CSRs shortcuts and quick answers that saved call handle time. I made the mistake of telling a customer, "let me call your provider to get an answer for you," letting my supervisor and her floor manager give me the answer she knew the provider would give me, and then getting back on the phone with the customer to say, "the answer is x." QA caught one of these calls, interviewed my supervisor who had no problem throwing me under the bus, and even personally fired me with the QA agent, floor manager and HR manager in the room. My customer service skills were so good, I had four times as many customer compliments as any other employee, including supervisors. And I still got the axe. Ouch.
(Photo: nyghtowl)
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Comments:
To paraphrase the Dalai Lama - If you can help, help. If you can't do no harm. Free Tibet!
Denying the claim in the chance it might be fraudulent doesn't seem like a valid reason.
I had to leave a company because I got tired of lying to customers about their "warranty" coverage for their furniture. They paid however much to Levitz or Macy's (any Federated company, actually) or whatever furniture store for this "coverage" (please not, it was NOT insurance, at least that's what they told the Florida Insurance Commission) in case something happened to their furniture. Stains, pieces falling off, etc.
These people got jerked around so much, and I had to bald face LIE to them about the whereabouts of their shipments (no tracking numbers ever given out, I didn't even have access to that information). And this was just furniture! Not even something important like health coverage.
So, Jason, I for one am glad that you were able to do the right thing. Even if this person was a fraudster, you helped out someone that you felt really needed it. Of course, after they fired me, I probably would have given a report to whatever federal department they had to answer to.
If it's that easy for fraudsters to game the system, then obviously there hasn't been enough fraud to justify fixing the way the system works. I'd say you did the right thing; I'd rather see a fraudster get away with their scheme than a legitimate request get denied because a company is greedy.
i know a place that's hiring people like jason- we're adamant about ethical treatment of our customers.
one time that i felt i had to step over the line i went right to my supervisor's office after the call and said "hey, i just broke all the rules. in case you pull the call for quality"
then i explained that the customer wanted to know if our [medical] product could cause her lungs to burn. a little investigational conversation helped me determine that she had started feeling that sensation when she was cleaning the bathroom.....
anyone? bueller? bueller?
yeah, she read me the back of the cleaning products and i just flat out googled poison control for her area, told her to hang up with me, call that number and tell them just what she said to me. so she could be treated for inhaling chlorine gas.
we're not allowed to look up phone numbers for people. or give advice.
my boss said 'let me make a note of the time of the call and just won't pull that one'
if i were jason - i'd rather get scammed than live with knowing i might have contributed to needless death and suffering
He told her she had a legal right to challenge the denial. He followed the law. He did nothing wrong, i would have reported the company and sued for wrongful dismissal if i was fired.
Insurance companies have an affirmative obligation to help their insureds - yes, even to the point of telling customers they can appeal decisions, or that they have claims that they didn't already know about (but the insurance company does).
I don't know how this extends to COBRA, but I have a hard time believing it doesn't.
If there is a problem with fraudsters, the solution is to fix the system - NOT to refuse to tell anybody about the system they're entitled to use.
You did good, Jason.
From what I read, even if the 9/11 lady was a fraud, all you did was give her the information that the denial could be challenged. Thats simply information that would allow someone the ability to prove their situation through an appeal process rather than rubber stamping what may be fraud.
Nicely done - when my wife got sick our insurance company tried to stick it to us big time. It was 90% luck and 10% smarts that they didn't succeed. It strikes me as pretty crappy that hard working people who pay for insurance have to put up with crap like this, AND pay the huge portions of bills that the insurance company worms out of covering, AND pay for a bunch of freeloaders on welfare to get the same treatment for free with no BS from insurance companies. Now our nation is on the way to Socialism. In the short run atleast the medical system should improve. Long run - I'm glad I dont have any kids because the future is gonna suck!
@B: That is the pat excuse insurance companies use to routinely deny claims in order to save money. Instead of figuring out if it is fraud or not they reject because "it might". Since just about anything might be fraud it is an all purpose answer for any question.
@fleebailey33 - Nice use of logic there. I'd hate to live in your world with only two options for anything.
Insurance companies technically are supposed to help those they insure but there is just too much conflict in the industry these days because they are obsessed with short term profit.
I had to laugh. Our previous health insurer had these people who were supposed to be health advocates for the patients. Now coming from the clinic I used I could understand this, that would make sense. Coming from an insurance company that had a track record of screwing me at every possible opportunity not so likely. This advocate from the insurance company called me like a stalker multiple times a week, sent me post cards etc. The supposed guise was to help you handle your medical condition. Sure an insurance company has a vested interest in you not ending up in the ER or with some major medical problem if it can be prevented but I certainly didn't trust them to give me advice about what was medically best, only what was in their best interest financially.
As CSRs, our job was supposed to be answering COBRA questions and working as customer advocates in resolving COBRA issues.
Jason, I see no conflict whatsoever between what your job description called for and what you did. Regardless of what happened "in reality", you did just what your company told you to do. In reality, your managers were heartless SOBs (or their managers were, more likely) who routinely violated, at the very least, the spirit of the law.
What you did was both factually AND morally right. Sleep peacefully, Jason.
Look, if the CSRs don't help people, who will? Certainly not the company. Rock on, dude.
@NRobertMoses: Isn't that the Hippocratic Oath? Like most religious leaders, I imagine that the Dalai Lama gets his chestnuts from bumper stickers, Reader's Digest and fortune cookies. And I worry that "Free Tibet" actually means "restore the theocratic serfdom." Yay.
@Jason: Good job, buddy! We should all be working undercover at work for our fellow human beings as far as we can push it. You did the right thing.
@ everyone: Once again, we need to END the private health insurance system in this country, they prove time and time again that they weasel out of the ONLY reason we pay them. Single payer now!
Jason, do not feel bad about trying to help. If she was a scammer, YOU'RE not out anything, and since you obviously think she wasn't, helping her was the right thing to do. Your bosses sound like giant assholes.
@acwatts:
Wait, so you admit that people on government-run welfare right now are better off. And that you get jerked around by the privately-run insurance company (because their only motiviation is pure profit). And end with the conclusion that socialized medicine is a bad thing in the long run? I know people have different viewpoints and all, but I can't for the life of me see the argument you're trying to make.
I did the same thing when I was teacher. A student of mine had a legal document (an IEP) that stated the school must make certain academic accommodations, but our principal ignored it and told me to do the same. The parent came to me for help, and my principal warned me that if told her of their rights or otherwise I advised her in a way that would cost the district money, I could be fired. So, I called the parent from a pay phone and told her of her rights, who to call, etc. The eventually child got their proper education.
He is saying our current mix of half private half goverment helth care sucks and will be better under a total goverment system. However the rest of the goverment intervention that comes with it will be worse then the current overall picture.
It's incidents like this that I'm in a different line of work now. That, and the nepotism at the job. It went well when the supervisors liked me, not so much if they didn't.
The CSR did the right thing. I've called police five states away to report that a caller told me someone was trying to kill her - she sounded like a nutbar, but I could not have looked at myself in the mirror if I didn't say something.
@coren: The unfortunate truth is that investigating takes time - and sometimes it's not so cut and dry. Her claim - relatives died in 9/11 - could have been substantiated through death certificates. Easy enough to prove.
But the fraudsters will come up with all sorts of inability to prove a negative junk to get through things. Or want to know why they have to be "further traumatized" by providing proof of deaths, layoffs, witness protection programs, limb dismemberment and whatever else they think will tug at heartstrings.
It's heartbreaking. It really is. In my CSR days, I was suckered more than once trying to go above and beyond only to find out that a customer was all to willing to take advantage of a hurricane, tornado or even a killing spree in the news and make it connected to them and why they needed special treatment. Everyone that's ever spent time on the phones has experienced this - and it makes those with real problems suffer.
Shitty people ruin it for everyone.
I'm glad the story submitter let his gut speak for him and he figured out a creative way around the problem. He found his win-win. It's a shame the shitty people still have him hoping she wasn't a scammer (scammers are great criers, by the by - and they LOVE telling you how much God loves you).
@Mr. Duck Sauce:
It's "you're" and "grammar." If you're going to rip on someone else's writing skills (who simply forgot a comma), try not to make your correction more rife with errors.
I'm not trying to nag, but what is going on with the reply button?
Great to see the private market providing individualized, appropriate, consumer-oriented yet cost-effective health care. I'm sure that the patient's husband and daughter, looking down from Heaven after being struck down by 9/11, brush away a grateful tear with their wings that they left their ailing mother in the more-than-capable hands of The Best Medical System on the Face of the Planet!
(Mad props to the rule-breaking employee who proved he retained his immortal soul, in spite of working for the insurance companies)
I swear to GOD I am not blaming the poster, but I have not heard of a Saving Private Ryan-esque loss of both a father and a daughter during 9/11.
Which is better: that the innocent get justice or the scamsters get a free ride?
If you don't know which side of that coin you're on, I suggest you figure it out soon before one of these moral dilemma smacks you in the face.
@Stephmo: The fact that the insurance company was scammed is no excuse for them breaking the law, which is what the CSR was instructed to do.
What's really bad about COBRA is that fewer than 10% of eligible customers actually use it. Why? It's often more expensive than just getting a new policy from another insurance carrier. My mom was recently quoted an outrageously high premium through COBRA. We shopped around, and found a premium that was half what it would have been under COBRA for roughly the same coverage.
The above is one of the best arguments I've ever read on Why Americans Need Single-Payer Universal Healthcare.
@N.RobertMoses: Free Tibet? I'll take it!
China, I have something you want...but it will cost you...yes...ALL the tea!
how would you NOT be doing the right thing by helping a cancer patient get coverage, especially one whose whole family died, and who was ONE day late? this is gnawing at you, really?
You didnt even break the law, you broke some policy at work for someone you believed in. If it was a scammer so be it. Thats what investigations are for. This should be on your resume.
Its like the old interview question: you find a bottle of alcohol in your workmates locker, a violation of policy. What do you do?
Wrong answer: Report them to my boss.
Right answer: is it open? is it a nice bottle of wine, or a bottle of cheap liquor? Is it in a bag or just sitting out? Is there a special occasion coming up? What else is in the locker? Half empty bottle Jack; tell co-worker to turn himself in or be reported. Bottle of nice wine, wrapped; tell co-worker to put it in his car.
the spirit of the law should always triumph over the letter of the law.
@B: That's the crappy thing--he wasn't breaking the law. She had the legal right to appeal; since he didn't have the legal obligation to tell her that, his company was allowed to forbid him to do so. And, of course, she would then have had a tough time finding out she had that right. Hooray for the company!
Maybe there needs to be an insurance equivalent of Miranda rights. Trim 'em down, require everybody in the business to recite them to their customers. Let them enter popular culture enough that even people not in insurance battles have an idea of the guidelines.
At any rate, Jason, I think what you did was fine, and I don't agree that "the policy was there for a reason." If you didn't have the tools to distinguish legitimate claimants from fraudsters, which it sounds like you didn't, it's up to people actually examining the claims to determine. The policy wasn't weeding out fraudsters, it was blocking denial appeals, with the additional characteristic of penalizing the most physically debilitated, since they're the least likely to have access to other information.
@Mr.DuckSauce: Your grammar is even worse. When attempting to correct someone, especially grammatically, you should ensure that yours is perfect, less you look like a fool. You do. (You're, grammar).
@BuddyGuyMontag: I was wondering about the confluence of events myself. However, I think that everybody's entitled to exercise their right to appeal an insurance denial, so I can't consider the result undeserved whether her story is true or not.
Here's the problem though...
I just spent a few minutes doing a few searches on CNN's 9/11 tribute. One of the things on CNN's tribute is family relations who died on 9/11.
Several husbands and wives died together on 9/11. Several families died on 9/11. Several fathers and sons died on 9/11.
Unfortunately, I can't seem to find a daughter/father combination dying on 9/11.
@floraposte: The problem is, she lied about losing people on 9/11. (see below post) How do we know she wasn't lying about cancer and just scheming to get COBRA coverage?
I hate to sound heartless, but there are a LOT of scammers out there, and there are a ton of them who used 9/11 to prey on people, especially in the months after the attack.
The thing is, 7 years later, we know exactly who died so some fact checking that the CSR may not have had access to at the time says that she may have been fradulent.
Can someone explain to me what the potential fraud is here? I'm just not seeing it.
@acwatts: Um...how exactly is our country "on the way to Socialism"? Don't believe all the crap the pundits on T.V. are spewing.
Yes, we are heading towards socialized medicine. That isn't Socialism, and it isn't a bad thing. We've already got LOADS of social services in our society, like police and firemen. Are THOSE Socialist?
@BuddyGuyMontag: What I'm saying is that we don't have to know. Jason didn't have to know. If she was denied coverage, she had the right to appeal--to the people whose job was to assess the validity. Those are the people who mattered.
I get that the story particularly moved Jason because of this claim, and it's definitely ironic if it turns out that that very story is what marks her as a scammer. And my skeptical heart is warmed that you did actual and successful research on this; you're definitely my kind of BuddyGuy. And sure, it would be nice if Jason had made his moral stand for somebody less questionable.
But I still think that the basic policy of essentially blocking appeals because the company didn't want to pay, not because somebody's assessed the case as not appeal-worthy, is somewhere between bullshit and evil. And I don't think that right of appeal gets taken away from somebody because they're rude, or manipulative, or bonkers. She was denied something it was agreed she was otherwise entitled to because she missed the date by one day. I think that's a legitimate cause for appeal whether you're Tania Head [en.wikipedia.org] or not.
A good friend of mine was doing insurance claims while applying to graduate school for psychology. He encountered a similar problem with weight-loss medication. It's a very popular for abuse, so when a woman filled out her form improperly, he was told to deny her claim.
The woman wept uncontrollably, and she talked to him about how hard it is being overweight. Incredibly bright and someone who will likely be a leader in his field, he analyzed the caller and made the call that she legitimately needed the medication. He pushed through her claim.
I think I'd do a similar thing as you did. All you did was inform this person of their rights. While you cost the company money, you upheld the essence of the contract that woman had with the company within the law. The company has an obligation to follow all laws (as they certainly hide behind laws themselves to dodge payment) and honor the contract. Kudos to you.