More Tales of American Health Care 2

A recent study estimated that at least 44,000 people die every year because they don’t have insurance. Don’t you wonder how many with insurance die because their insurance company doesn’t honor their commitment to protect their health and their bank accounts?

Once more, folks; these aren’t stories from people without insurance. These are actual complaints from people who pay for health insurance; some of them have been doing so for many years.

There’s been a lot of talk about how great Medicare is. Well, it is better than what most of the rest of us find ourselves stuck with, but let’s get real here; Medicare has a lot of holes in it. Those holes are supposed to be filled by private insurance companies, in the form of supplemental insurance. Now, you would think that, because Medicare covers most of the bill for just about everyone, and all the insurance companies have to cover are co-pays, deductibles and the gaps present in Medicare coverage, they would take seniors money and run.

Not a chance…

  • For nearly a year, Al’s doctor recommended a nuclear stress test for his heart, on top of the standard cardiac tests. But his insurance company ignored doctor’s orders and refused to authorize the extra tests, asserting that regular testing would be sufficient. This assertion came despite Al’s history of heart disease, including a heart attack and a triple bypass. Al passed away this past February. The cause of death was heart failure, and the coroner found three blocked arteries, including two that were considered 100% blocked.
  • Sue’s 71-year-old mother was an active and healthy woman three years ago, when she suddenly began having severe back pain. The initial diagnosis from the doctor was osteoarthritis, and he prescribed pain medication. They didn’t work, and a closer look revealed that she had a herniated disk. The prescribed more pain medication, but her condition worsened. The doctors wanted to do an MRI, but the insurance company refused to authorize it. The doctors kept appealing, and the insurance company kept refusing. It took six appeals over the course of two months, until Sue’s mother couldn’t even move, and they had to rush her to the hospital. It was only when she was in the hospital that the insurance company finally approved the MRI. By that point, her herniated disk was so swollen that it severed her spinal cord. Sue’s mother is now 74, paralyzed and confined to a nursing home.

According to Republicans, apparently, we’re all entitled access to medical care, because we can all go to the ER. How many times have you heard this excuse thrown about by these geniuses? Well, apparently, if you have insurance, and you think you might need to go to the ER because you feel like crap, you’d better check to make sure you have plenty of money in your bank account, because you may not be in better shape than the uninsured:

  • Dan vomited blood one night, and immediately high-tailed it to his primary care physician the next morning. The doctor gave him a brief examination, and told Dan to  get to the emergency room immediately. Once there, they put him through a half hour series of procedures that cost nearly $5,000. The insurance company actually refused to cover any of it, saying that his coverage only included emergencies. As the insurance company saw it, because he waited several hours before going to the doctor, and the doctor sent him to the ER, vomiting blood didn’t constitute much of an emergency.
  • Karen went to the emergency room one night with a severe strep throat, which had already been diagnosed by her primary care physician. The doctor prescribed antibiotics, but as is sometimes the case, they were having no effect. When she showed up at the ER, she was having a difficult time breathing because the swelling was causing her throat and airway passages to close. An ER doctor immediately gave her a steroid shot, as well as medication designed to open up her airway. They suggested admitting her, but because she had two young children at home, she declined. Instead, they prescribed a different antibiotic, and she went home. A week later, she was back to something resembling normal. That is, her health resembled normal, not her bank account. The co-pay for an ER visit on her plan was supposed to be $75. Instead, the insurance company decided that she “didn’t meet the criteria” for an emergency room visit, and refused to pay the bill, which came to nearly $1,500. She couldn’t breathe, and she was in enough obvious pain that a trained medical professional immediately shot her with steroids, but according to her insurance company she wasn’t “sick enough” to show up at the ER? Not only that, but when she and the rest of her family showed up at the lab to have throat cultures taken in relation to this illness, the insurance company charged her co-pays for a doctor’s visit, even though none of them actually saw a doctor at that time.

Some of you may be under the impression that, because you’ve had your insurance plan for many years, and never used it, your insurance company will cut you a break, should you have to use it at some point. Don’t be silly…:

  • Mark has been with his insurance company for 12 years. In that time, he had never made a claim, other than a primary care office visit. Then, a little over a year ago, he suffered nerve damage to his shoulder after an accident. At first, the only treatment for the shoulder was physical therapy. After two months, Mark’s insurance company announced that his benefits had run out, and Mark was forced to pay the therapy bills for the next seven months out of pocket. This, in addition to his monthly premiums, which were running just over $600 per month. At the end of the physical therapy, his doctor determined that Mark needed surgery. The insurance company approved the surgery, but refused to cover the physical therapy doctors deemed necessary for a full recovery because, again, he supposedly reached his “maximum benefit level,” which insurance company officials have yet to explain.

Having a baby? Isn’t it great? It’s a tense but exciting time, to be sure. And believe me, the baby is a treasure. Make sure you have health insurance, though, because it can become expensive. Of course, if you think your insurance company would never screw expectant parents, well, you don’t know how heartless these bastards can be…

  • Sherry’s primary care physician scheduled her for a 20th week ultrasound, to check for possible abnormalities. This was routine; she’d done it for both of her previous children, and her insurance policy said they pay 90% for every medically necessary ultrasound, with no limit. (When you see the term “medically necessary,” you can probably guess what’s coming.) The doctor examined the ultrasound image, and determined that her child’s nuchal fold was a bit thicker than normal. As this is considered a preliminary indicator for Down’s Syndrome, the doctor referred her to a specialist, who performed another ultrasound. Well, apparently the insurance company figured Sherry was just messing around; you know, perhaps she was just darting around town, getting images for her scrapbook, so they denied her on two counts; they claimed the ultrasounds were not “medically necessary,” because they were “experimental and investigational.” Can we get a “DUH!”?? Sherry is now out almost $1,100, and continues to pay her premium every month. Go figure.
  • Mrs. K’s husband had been working with his employer for almost ten years, when suddenly, said employer switched insurance companies. Upon notice of this development, Mrs. K immediately called her new insurance company to make sure her current pediatric medical group was covered under the new plan, because she was pregnant with triplets, and because her doctors had labeled her pregnancy high risk. As such, she had been seeing a specialist in multiple pregnancy. Of course, her new insurance company assured her there was no problem; these doctors were in-network, and to continue seeing them. Two months later, of course, bills started pouring in from the medical group. The insurance company, however, only paid 70% of the bills, because – are you ready? – they were “out of network. On top of all of the other expenses involved with having triplets, they were forced to incur nearly $5,000 more in bills because of the faulty information. Not only that, but the medical group put the bill into collections, and their credit rating took a serious hit. That, and at the 7-month mark of her high risk pregnancy, she had no choice but to switch doctors to one in-network.

Imagine being forced to switch insurance companies suddenly, through no fault of your own, and having to change obstetricians when you’re seven months pregnant. Well, you don’t have to be pregnant to feel the ill effects of a sudden switch in coverage:

  • Becky’s husband’s company switched insurance companies last year. Between their contribution and his employer’s, their premium is nearly $1,200 per month, or more than $14,000 per year. Yet in the year since the switch, they have made a grand total of two claims, and the insurance company has denied both. In the first case, her husband has a high fever on a Sunday, so he went to a nearby urgent care clinic. The insurance company refused to pay, calling it a “coding issue” and blaming it on the urgent care facility. The urgent care facility claimed that “every other insurance company” accepted such “coding,” and claimed they couldn’t change it. So, Becky’s family was out $200 for that. A few months later, while they were on vacation, their two year old son had a fever of 105. Again, it was on a Sunday, so they took him to the nearest hospital, where they found out he had an ear infection. A month later, they received a bill for almost $800; the insurance company had refused to cover any of it. According to the insurance company, they only cover emergency treatment in which a “member has a medical condition that causes sudden symptoms that are severe enough that a person with an average knowledge of health and medicine could reasonably expect that not receiving immediate medical attention would put his or her health at serious risk,” which they said was not the case this time. Now, what parent would NOT consider a fever of 105 in a toddler worthy of “immediate medical attention”? Keep in mind, they pay this company $14,000 a year. What for?

If you’re paying for health insurance for your kids, because you’re trying to be a good parent, and provide properly for them, don’t relax just yet. If your kid plays sports, you could be in deep trouble in today’s system:

  • Mike has four healthy children, and makes a good living. He also pays more than $15,000 per year for his health insurance policy. Late last year, his daughter, who is a 16-year-old tenth grader, was injured playing lacrosse at school. Immediately after the injury, this athletic girl, who rarely complained of pain, was unable to stand or sit for any length of time, she couldn’t lift any more than about 3 pounds comfortably. She could only turn her head to one side, and she had a sharp pain down one leg, so Mike took her to the emergency room. There, they took an x-ray, which indicated that she had no broken bones, although she did have mild scoliosis and spina bifida, as well as a sprained neck. The doctors prescribed strong pain medications and muscle relaxers, but after a week, she was experiencing pain in her arms, and her spine began to swell. When her doctor ordered an MRI of her spine, however, the insurance company refused. When the doctor made a personal plea, they allowed an MRI of only the lower spine, because of the spina bifida. Apparently, the insurance companies don’t consider the spine to be a crucial part of the body.

And God knows if they’ll actually be of any assistance, should your child develop an eating disorder or some similar malady. Check this out:

  • Meg and her husband have been paying for family health insurance with the same insurance company for many years. About two years ago, they were worried about their teenage daughter’s weight loss. They took her to their primary care physician, who diagnosed the girl as bulimic. But the insurance company refused to pay for treatment, because they decided the condition was psychological, not biological, and their state only guarantees coverage for biological conditions, not medical. How did they make this determination? They somehow received information that she had written about the eating disorder in her diary, in emails to friends, and on her MySpace and Facebook pages.

If you think the health insurance companies only deny the biggest claims, you’re just not paying attention. Even stuff one would assume would be covered can be denied for the silliest of reasons:

  • Marie is 36 years old, and she went to her doctor for her first mammogram last November, because the AMA recommends that women between the ages of 35-40 get at least one baseline screening at least once before age 40. Her insurance company paid the $340 cost at first, but several months later reversed themselves, because their policies don’t cover screening mammograms under the age of 40. She appealed, and even submitted a note from her doctor, and the insurance company once again denied it. Apparently, a woman must have a lump before the insurance company will pay for a mammogram.

I actually have quite a few more of these stories, and more are coming in. In addition to other articles I’m working on, I plan to include a few more such stories each week. If you know of other stories send them to me.

If we’re going to fight the smear machine, the most effective way to do it is with facts. There is no way right wingers can read stories like this and argue competently that the United States has the “greatest health care system in the world.” All of the above stories are actually legal under our system (except perhaps the privacy issues inherent in the story about the emails), and that is the heart of the problem. Insurance companies can do any damn thing they want, and health insurance reform, including a strong public option will change the playing field.

Keep on fighting the good fight… don’t give up.

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