So You Think You Have Health Insurance?
One of the problems we are having in this debate stems from the fact that something like 78% of the country has health insurance. Since insurance companies only insure healthy people, the vast majority of those getting health insurance rarely have to use it; their boss simply pays their premiums for them, and they assume that, should anything happen, they’re covered.
Think again.
A few weeks ago, I put a call out for stories from people who have experience dealing with health insurance companies, and have been inundated. (You can put the word out, too. Send stories to healthcrisisnotes@gmail.com.) I have also gained access to actual complaint files from a couple of insurance companies.
I have compiled many of these stories below. While many of these are not extreme horror stories, the problem is clear. The intention of posts like this is to articulate how health insurance companies operate, and why we need serious reform. Feel free to show them to those relatives and friends who insist the health insurance system is fine. This is only the beginning; I literally have hundreds of stories.
It’s not fine. We’re in serious danger, folks. What these stories show is a system that has broken down. But as long as a few people are profiting mightily from, scumbags are desperately trying to save it. Doctors and hospitals care about their patients for the most part, and they mostly perform admirably. But private for-profit health insurance companies are bastards. They don’t care about their customers, meaning either patients or doctors; they only care about making money. For those who think that characterization is a bit over the top, read these stories, and the ones upcoming. These are real people making real complaints.
Please note that I’m not giving the names of the insurance companies involved, for a couple of reasons. For one thing, I have no way of verifying the actual veracity of some of the claims, although since most of them are formal complaints, it seems unlikely they’re lying. But it’s also because it’s not about individual companies. This is about a system that is horribly broken..
If you think you have insurance, and you think you’re covered, think again.
· Louise started a new job and a received a new health insurance benefit with the same insurance company she’d been with for years. Three months later, she went to the doctor, who discovered an ovarian cyst. The in-network doctor immediately checked her into the hospital, where they removed the cyst and submitted the bill for nearly $18,000 to the insurance company. The insurance company refused to pay the bill, however, claiming it as a pre-existing condition, even though the doctor submitted a signed affidavit to the insurance company that it was not a pre-existing condition at all. Again, this was a new policy with the same insurance company.
· Ro actually read her policy carefully, and found that colon screening was covered, so she actually went to the doctor for a colonoscopy. Unfortunately for her, she was diagnosed with diverticulitis. Now, you may be wondering why that’s unfortunate; catching such a thing should be the whole point of colon screening. But her insurance company actually determined that, because she had actually been diagnosed with diverticulitis, the bill was submitted as a “diagnostic exam” and not as a preventive colonoscopy. Funny thing; her insurance covers the preventive care, but diagnostic colonoscopies actually fall under the deductible, which in her case is $3,000, so she has to pay the entire $1,800 bill. In other words, if you have to go in for a preventive colonoscopy, and they find anything at all, expect to pay twice.
· Millie is 82 and mostly covered by Medicare. She was hospitalized for congestive heart failure, a day after she had made a partial payment to her insurance company for her Part B premium – she’d paid $94 on a balance of $198. After almost a month in the hospital, and another month recuperating at home, she realized that she hadn’t received a bill from her insurance company. She called them, only to find out that she had been cancelled, due to partial payment. No notice; they just dropped her.
· Alan was recently diagnosed with Crohn’s Disease. His doctor prescribed a drug used to treat active Crohn’s. (Pay close attention to the word “active;” it’s important.) The insurance company requires a pre-authorization for the drug in order to cover it. The first time the doctor’s office submitted a pre-authorization, the insurance company denied it because the doctor’s office “only” stated that it was for Crohn’s Disease, and didn’t use the word “active.” The doctor corrected the problem and re-submitted. Alan then received a letter from the insurance company stating the drug had been approved. Unfortunately, when they took the prescription to the pharmacy, the insurance company denied it again, saying it was “approved for quantity, it was not approved for distribution.” (It’s okay if you scratch your head and say “huh?”) Well over a month after diagnosis, the insurance company still has not given approval for the drug. Alan cannot afford the cost of the prescription out of pocket, but because of the active Crohn’s, he cannot eat without severe pain, and he’s losing a lot of weight.
· Monica went to a local hospital emergency room at 1:15 AM when she felt excruciating pain in her lower back and right leg. The doctor told her she would need surgery on her lower spine. Being wary of such surgery, Monica decided to get a second opinion from a chiropractor. The chiropractor assured her that she could cure the pain, and called the insurance company, who verified that she indeed had insurance coverage for chiropractic care. The insurance plan clearly stated that she was covered for 20 visits to a chiropractor during a plan year and she would be well under that number. They covered the first four, but then someone at the insurance company decided that she had no medical reason to see a chiropractor. Then, when she argued with them over the visits they refused to cover, they reversed themselves on the first four, as well. She filed an appeal, which was, of course, refused. But when they refused this time, they moved the goalpost. This time, they didn’t claim that she had no medical reason for the visits, but rather, that the chiropractor engaged in activities which the insurance company found to be “inappropriate.” They did not explain further.
· Last January, Jen found her 4 year old son unconscious in his room in the middle of the night. His breathing was shallow, he had a bloody nose, and it was 30-45 minutes before he regained consciousness. In the emergency room, the doctor advised that he see a pediatric neurologist as soon as possible, because of a possible seizure. There were no such specialists within the area network, which the insurance company describes as within a 30 mile radius of their home, so they told Jennifer she could choose one, which her son’s pediatrician did, and they would get him pre-certified as in-network. So, they make the appointment. Unfortunately, the day before the appointment, Jennifer received a call from the insurance company, and said they refused to pre-certify the specialist, because they found another provider “in their area.” The provider they cited was more than 100 miles away, a more than two hour drive. She called “Member Services” for the insurance company, and they could not explain why she was denied, but that they would let her know at her appeal. Meanwhile, she had to cancel an appointment she’d had for three weeks, and was forced to wait, not knowing what is wrong with their son, and anxiously dreading another seizure, not knowing if the next one will be even worse than the first. She even attempted to get them to approve an adult neurologist, only to find out that none of them will see anyone under 18. So, for months, she was forced to wait. Imagine being a parent and having that hanging over your head. (By the way, isn’t that the “waiting lists” we’re supposed to be so afraid of?)
· Anna, a nurse in a doctor’s office tells the story of a child who was brought into the doctor’s office with more than 80 warts on his fingers and arm. The doctor administered anesthesia, and removed them all and only billed the insurance company for 24 of them; a bill of $1700. The insurance company refused the claim, however, because no more than 3 warts can be removed on any single visit. That means, in order to be paid, according to the insurance company, the child would have to be brought in every day for 28 days, receive an injection each time, and live with the warts in the meantime.
And just in case you think you can get coverage anytime, as long as you’re young and healthy, here are a few cautionary tales:
· Julie had insurance coverage all through her childhood, through her parents’ insurance plan and through her university’s group plan. In that time, she was almost never sick and she’s only 22 years old. But she was recently denied coverage by the same insurance company that her parents had been paying premiums to all of her life, because she was 50 pounds overweight, because she was taking oral contraceptives to regulate her menstrual cycle, and because she was prescribed some social anxiety medication for a time when she was a teenager.
· When Brad’s daughter graduated college at the age of 23, her coverage on his family insurance policy ended, so while she was looking for a job, he shopped for and paid for health insurance for her. He found it a daunting task, but finally decided to stick with the same company that had carried his family’s insurance all those years. After she provided a complete medical history (now, keep in mind, this is the same company that had been covering her throughout her childhood), they accepted her coverage. They noted no exclusions at the time of application, and they sent the policy to her, even though Brad was paying the bill. Months later, while visiting his daughter, Brad thought to look at her policy, and noted that it contained a major exclusion, for medical problems related to her spine. See, she had previously been in the back seat of a car that was rear ended at slow speed. The accident included no hospital time nor permanent injury.
And if you get older, you’re completely screwed, at least until you turn 65:
· Jimmy has never been hospitalized, has never had a major illness, he doesn’t smoke, only drinks an occasional glass of wine, and he’s less than 10 pounds overweight. He’s been paying premiums to his current insurance company for more than 25 years, without a claim, other than an occasional physical. He doesn’t even take prescription drugs. Yet, his insurance company recently raised his premiums 25%, just because he turned 55.
And make no mistake: if they can find any excuse, they will drop you if they want to. It really doesn’t matter how long you’ve been paying them:
· Manny was self-employed and, for 15 years, had always paid his quarterly premiums to his insurance company on time, and amount that totaled hundreds of thousands of dollars. There are four people in his family, and rarely has anyone made a claim other than annual physicals and allergy medications. But this quarter they raised his rates, and he miscalculated the amount, and the payment was $31 short. Instead of calling Manny, and asking for a $31 check, they simply canceled him. They had the payment for more than two weeks, but didn’t notify him of his shortage until after the cancellation date.
And for those of you who think insurance companies only screw patients, you might want to consider this:
· Ellie is the owner of a really small business, who provides health insurance for her employees, and has done so with the same insurance company for 25 years. Her contract runs 12 months, and she’s billed monthly from the 15th of one month, to the 14th of the next month. One of her employees will be leaving on the last day of the month, and will be covered by a new policy beginning the first of the next month. But when Ellie called the insurance company to remove the employee from their policy effective the last day of the current month, they refused. Therefore, this small business was actually forced to pay $350 for someone who will no longer be employed, and will be covered by another company. She should have told them the employee had cancer; they probably would have returned the $350 pronto.
Like I said, I literally have hundreds of such stories, and will probably be inundating you with these over the next few weeks, until we get health insurance reform passed. Pass them around and let’s make this issue seem more real to people. And feel free to give out that e-mail address, and send me more stories.
