Life Disrupted, Interrupted and Corrupted: A Recent Experience with Healthcare Insurance Coverage

In the past two years, my wife and I learned firsthand that life can change in an instant.  And, we learned firsthand about the complexities of our current healthcare and health insurance system.

My Wife’s Emergency: Life, Disrupted

Prior to Thanksgiving break in 2013, my wife suddenly found herself with pain on her left side, below her rib cage.  In 20 years together, I had never seen her so uncomfortable.  Clearly, it was something serious.

We raced to our local hospital.  After a night in the ER and several tests, we canceled our holiday travel plans and visited several doctors the following week to determine the problem.  With no thought to holiday preparations, we ate leftover vegetable soup instead of turkey on Thanksgiving Day.

We scheduled a surgical consult on Friday, December 6.  In the days leading up to the consult, she started coughing persistently and experiencing pain behind her right knee.  Upon hearing these additional complaints, the surgeon himself wheeled her to the vascular lab in the hospital adjacent to his office.  Tests showed a deep-vein thrombosis in the leg.  Not wasting any time, the surgeon immediately admitted her, and she did not leave bed for nearly a week.

Thus began a tense 72-hour window to stabilize her condition and prepare her for emergency surgery.  Fortunately, the surgery was successful, and I am happy to report she has recovered well, even running in a competitive 5k race the day after New Year’s 2015.

The Aftermath: Life, Interrupted

During 2014, my wife dealt with a myriad of challenges as she recovered from the surgery, regained her core strength and patiently waited as her body naturally dissipated the deep-vein thrombosis.   And, she and I wrestled with the challenges of navigating insurance coverage, along with the bills and various correspondences.

Three notable experiences from last year leap to mind:

  • In late January 2014, we started to receive an avalanche of paperwork from the three ‘agents’ involved in her care: our health insurance company, the hospital itself, and the group that owned the hospital.  Each sent triplicate – sometimes quadruplicate – copies of bills for services rendered, none of which seemed to directly correspond with paperwork from the other two.  To date, we continue to receive statements, even though we are paying what we owe, as confirmed by our insurance company – and our checking/credit card statements.
  • We unwittingly learned that, while the surgeon himself accepted our insurance, the hospital affiliated with the surgeon did not, and had only recently decoupled from our insurance company.  Her emergency admission was ‘necessary’ in order to maximize our coverage: a frustrating realization.  In fact, we received a letter from our insurance company just a few days ago firmly reminding us that ‘X” Hospital (where she had her surgery) was not covered under our plan – as if we needed a reminder!
  • In September 2014, we received a letter from the hospital, asking for the payment of a mid five-figure amount ‘not covered by our insurance’, to be paid ‘as soon as possible’.  Fortunately, my wife’s company (through whom we have coverage) offers a healthcare advocacy service who helps coordinate her insurance coverage.  We appealed the letter, and after an agonizing two-month wait, learned that our insurance company and the hospital reached a settlement that reduced our out-of-pocket requirement for uncovered services by – no lie – 98%.   We learned later that the hospital, since being acquired by a larger healthcare group, routinely overcharges 1,000-4,000% for ‘basic healthcare services’.

Understand that we have good, comprehensive insurance coverage with relatively low out-of-pocket requirements.  That we are and have been consistent wage earners for many years.  That we are reasonably detail-oriented when it comes to our personal and financial well-being and record-keeping.  Still, we put several significant financial decisions on hold in 2014 until we sorted through the tangle of coverage and payments.  As of this writing, a full 14 months since the surgery, we are only now starting to see a light at the end of this tunnel, with balances finally starting to settle.

Health Insurance: Life, Corrupted?

In early 2014, the Kaiser Family Foundation released a comprehensive study of medical debt among people with insurance.  As the study states:

While the chances of falling into medical debt are greater for people who are uninsured, most people who experience difficulty paying medical bills have health insurance.   Medical debt can arise when people must pay out-of-pocket for care not covered by health insurance or to which cost-sharing (such as deductibles) applies.  Medical debt might also result from health insurance premiums that individuals find difficult to afford.  The consequences of medical debt can be severe.  People with unaffordable medical bills report higher rates of other problems – including difficulty affording housing and other basic necessities, credit card debt, bankruptcy, and barriers accessing health care.

The study is backed up with case studies and reports that cut to the heart of this basis thesis.  Cost-sharing (out-of-pocket expenses), the ratio of out-of-pocket expenses vs. income, and multipliers such as chronic conditions and multi-year treatments can all contribute to the financial struggles that some consumers experience in dealing with healthcare expenses – even those fortunate enough to have medical coverage.

In our case, we had access to resources such as a healthcare advocate to help us settle a dispute.  And, we were able to establish that my wife’s situation was truly an emergency, bypassing the potentially heavy financial burden of working with an out-of-network facility.  Had we not been in a position to challenge the system, I would be telling a decidedly different story.

But not everyone is as lucky, which is what we were: dumb-lucky.

Isn’t healthcare insurance supposed to help people?

Insurance companies, especially after the implementation of PPACA, are at a critical point.  Everyone now must have coverage, and insurance companies must simplify their processes and become more consumer-friendly.  They need to position themselves as customer advocates, not customer adversaries, and speak to their customers in clear, plain language.  There is no reason that anyone dealing with a major life disruption/interruption should have to suffer at the hands of this system, especially when they have coverage.