The clock is ticking

The clock is ticking

As I watch all the arguing, slurring, slandering and propaganda being thrown about while the powers that be struggle for control of our thoughts and minds, I can’t help but get a bit pissed off that while 47 million people are one illness away from total financial disaster and those that are insured don’t believe they are also one step away even IF they are insured, we are ignoring the basic premise of a universally available health care system for ALL Americans.

The Bullshit Aspect Of Our Healthcare System

I’m 55 years old and uninsured. The reason? Well, economics! To insure myself, my spouse and my son would be approximately $7,500+ a year in premiums. I’m self employed so I don’t have an ’employer’ to assist in that coverage. Even then they would only cover most of mine and not the family. As I grow older those premiums increase. Now, on top of that is the deductibles, co-pays, non-covered items, prescriptions, etc. etc. that won’t be reimbursed or paid in our behalf. Luckily for me i’ve been pretty healthy and haven’t had to incur expenses for medications, procedures, etc.

The Fear Factor

Insurance is built on fear. Period. The ‘..what if?’ question always pops up. Well, that fear spurs millions to pay ridiculous costs in premiums for limited coverages that exclude previous conditions and hundreds of other known health issues for the sole purpose of having the insurance company pay the bulk of a catastrophic illness hospital stay.

If you watch TV undoubtedly you see the ‘fear factor’ (not the show where they eat bugs) in almost every commercial. ‘IF you don’t want to stink…use this!’ or ‘Do you breath in and out? Well, you may have Breather’s Syndrome! You must use this product or…. !’ It’s a basic premise of sales. Instill the fear and sell them the product that alleviates it (the fear).

Why The System Fails

I’m going to talk about some personal experiences here. These are actual events that involved the need for medical care and how they were handled by our insurance carrier of which I will not name simply because they will probably sue because they can, not because what i’m stating is false. It’s 110% true. We were informed when purchasing the policy that maternity as well as general healthcare were all covered.

My Son’s Birth

Ok, this one is a doozy. Labor started early on August 31st and lasted well into the late evening. The doctor and nurses kept checking for the dialation measurements routinely but the numbers were stuck around a 5 for many hours (a 9 is when the baby is typically delivered). After further examination it was determined the baby was tangled in the cord and they recommended an emergency C-section. After deliberating with the wife we agreed to move ahead with their recommendation. Everything went fine and our doctor was one of the most respected pediatric care doctors in our area.

As good little policy subscribers do, we completed all the claim forms, submitted our info to the hospital, etc. etc. just like it was out of a textbook. About 60 days later we receive the notification from the insurance carrier… “We can not pay this bill due to the fact we do not cover C-sections”. WHAT?!  Ok, ok… let’s talk to our insurance guy who does his due diligence and reviews all text in their policy guidelines. Sure enough, there’s the one single line all by itself buried within all the other talk about maternity coverage that states:

“We Do Not Cover Cesarean Section”

Which happens to be preceded by:

“We Cover All Emergency Procedures”

Ok, so the argument is about to ramp up. The C-section WAS an emergency procedure prescribed by and recommended by a top surgeon who is on the carrier’s approved list. But, as their escape claus, they wouldn’t cover it. Basically they wouldn’t cover any part of it, actually. Not just the C-sections…NONE of the delivery! Hospital, medication, etc. etc. Even though it was an emergency procedure that little line in the booklet gave them their out. And they took it.

The damage? Just over $13000. Now, luckily we had a great insurance agent. To cover this what he did was file an Errors & Omissions claim (they have insurance to cover any misinformation that may occur) which then settled the entire bill. This, however, still took time and to protect our credit we had to pay the $13,000 out of pocket in the interim while this was settled.

Ok, so was this right? Fair? An emergency procedure that they ‘exclude’ from the emergency procedures they cover? I don’t get it.

Knee Surgery

My ex-wife needed orthoscopic surgery after years of pounding her body with aerobics (the price you pay for being fit!). We scheduled interviews with several doctors that were listed under the plan, chose one and scheduled the surgery. We sat right there in the coordinator’s office when she called our carrier and pre-authorized the procedure which was about $4,000.

After the surgery she had a long recuperation of about 6 weeks and then rehab time to rebuild her muscles. Sure enough, about that time the letter shows up about our coverage. This time, though, it wasn’t denying payment. It was the amount they would pay that was the problem. See, they were supposed to cover 80% and us 20%. Well, it sort of worked out that way but like this:

Should have paid: $3200 = 80% of $4000

They actually paid: $780

Ok ok, you’re wondering how that math works…. WELL, let me tell you! See, they don’t pay 80% of the costs, they pay 80% of the usual and customary charges for that procedure which is based on a chart they keep secret and use as their guide for payouts. We asked to see this chart… ‘No, you can not see the chart. It’s confidential’, they reported. Hmmm, ok, so based upon that you’re telling us that this pre-authorized procedure done by one of your approved physicians who quoted us $4,000 should have charged the ‘usual and customary charge’ of $975.00?!

Once again, we were stuck with the bill. Did we know about this in advance? Nooooo. Should they have explained this in advance? Yesssss. Did they? Nooooo.

We appealed…. to the Insurance Commissioner of California! He did nothing. We threatened to sue the carrier…they snarled and dared us to. We argued… ‘WHERE can you go to get this procedure for $975.00?!’ They had no answer. Especially since the 4 doctors on their list charged over $4,000. So, how do they come up with the ‘usual and customary fees’? Easy, look under ‘screw the subscriber’ and you’ll see it. They have all the power to say yah or nay. And the problem is…you won’t know until after you’ve had the care!

Stepson Gets Sick

Our stepson began to suffer from some deep pains in his chest. At 21 years old he was pretty healthy, a bit overweight, but healthy. So, we took him to the emergency room and later was admitted with a complex condition named Pluracy. Again, we had a group health plan that was to cover 80% of the expenses if everything jived, which it should have.

So, after 5 days in the hospital the bill was $43,000+ (yeah, nuts, eh? and they wonder what’s wrong with healthcare). When it was all said and done after his release the total was about $48,000.

I’m sure you can guess what’s coming next. Yep! After about 60 days we receive the letter… “We are cancelling your policy and returning the bills to the hospital unpaid. You had not disclosed a pre-existing condition on your application which is a violations…blah blah blah”. Bottom line… they won’t pay due to something not stated on the application. Funny, the pre-existing condition had nothing to do with the Pluracy and is totally unrelated. It was the mere fact that it wasn’t stated on the application that gave them their ‘out’ to not pay. The key is, even if we would have had that on the application they would have insured him. So what’s the difference??!

Now, here’s a 21 year old who gets sick, needs care and as a result is about to have his credit completely ruined because his health insurance carrier finds a mistake in the application that, to their admittance, made no difference anyway. To summarize how this was eventually settled, again we had the insurance agent (different one) file for an Errors & Omissions claim. We received a settlement for about $35,000 of which was to be paid to the various entities to cover the bills.

Well, a funny thing happened on the way to the bank. Get this. We contacted all the doctors, hospitals, etc. to get the final $ amount they wanted in order to go away happy. The entire bill was settled for about $10,000! So… where did the $48,000 bill go?! This is one of the major problems with health care…it’s a license to rip off the insurance companies! When they thought we were covered the bill was $48,000. When they found out we weren’t the bill was just $10,000. Go figure. WHAT is the difference?! Do they just make up a new set of numbers to send to the insurance companies?! It’s absurd! Bottom line? We paid everyone off and got a new car for him. Take that, insurance company!

Not to mention, almost $10,000 a night in a hospital room is something I just can’t fathom. Can anyone explain this?

In Summary

Ok, let’s take a look at these problems and real-life occurrences. First, WHY do they not find those little issues in your application until AFTER you’ve spent $48,000? Second, HOW do they determine what they consider the usual and customary fees? And, NOT LAST, why do we allow some profit organization’s board of directors to determine who gets coverage and who dies?