Excuse me while I laugh. Insurance is a contract arrangement, and it's largely out of the hands of the individual. It's a contract between your employer and an insurance company--and every employer-based plan differs from the other. Separate contracts, you see. Just because we both have Blue Cross coverage does not mean that our plans are the same.
I am the veteran of six different employer-based plans since 1998, the year Robert developed his medical problems: The Guardian, Cigna, Blue Shield of California, HealthNet, Kaiser Permanente, Blue Cross/Blue Shield Federal Employees Program.
Insurance companies nowadays develop a standard base plan that covers doctor's office visits (internists and basic specialists), standard hospitalizations, emergency care, and standard surgeries and other operations. Most employer-based plans have 'riders' for other areas of care and service, and these include: prosthetics and orthopedics, dental care, prescription drugs, durable medical equipment, medical supplies, eye treatments, mental health, and therapies (physical, occupational, speech). That is, these sorts of care items are optional, and are not covered by the basic plan--your employer has to elect to pay for these riders for you. In a car accident? That doesn't mean they'll pay for physical therapy. Lose a leg? Doesn't mean you'll get a prosthetic leg. Have an accident and end up a paraplegic? Doesn't mean you'll get a motorized wheelchair so you can be independent.
And that doesn't even cover the issue of 'exclusions,' which are contained in a list at the back of your policy papers, the effect of which is to state both clearly and through a certain amount of dissembling, what your policy does not cover at all. And that's not just cosmetic surgery.
What does this mean for me or for you? Let me explain through the use of examples.
First of all, there was the bath chair and toilet seat incident. Robert requires support in the bath and on the toilet--he requires supported seating for all activities. Myself, I think bathing someone is medically necessary (as is the ability to avail yourself of a toilet--wearing diapers forever creates all kinds of long-term medical problems). But, keeping it delicate here, if you don't bathe, you develop rashes and infections. Me, medically necessary. Blue Shield of California, not so much. Technically, bath chairs and supported toilet seats are pieces of durable medical equipment. Not according to Blue Shield of California. We had a rider for DME. But there was an exclusion in our policy, not about bath chairs, but about hospital stays.
If you were hospitalized under that plan, Blue Shield of California would not pay for your cable TV, for your tissues, for your toothbrush, for any personal or sanitary items you might need while at the hospital. I pointed out that the wording of this exclusion very clearly stated it was in relation to hospital stays. Oh, no, they said, it covers home situations as well. I asked them to explain and they dissembled. I complained to an oversight agency in the State of California, whose representative was empathetic, but said that the typical initial review stood up for the insurer in this case. He urged us to litigate, because he thought we had a chance, but, alas, we lived in Maryland and getting involved in litigation in California was going to be more than buying the two items, the combined cost of which was over $1,000. The purchase of these items did not count toward our deductible, nor did it count toward our out-of-pocket maximum for the year. They were simply non-covered items.
Then there was the time we discovered that the payroll company through which Roger purchased health insurance for his own company had not purchased a prosthetics/orthopedics rider. The contract was between the payroll company and the insurer. That insurer was Kaiser. This omission was brought to my attention when my medical supply company charged me for Robert's replacement feeding button. This is a small medical device that fits into a surgically-created hole in his stomach. The button is held in place behind the stomach wall with an inflatable balloon, and it creates a port on the outside to which feeding tubes and syringes can be attached so that food and liquid can be delivered to his stomach. Because the balloon and canal deteriorate over time, and that deterioration can make the equipment unusable and cause infections, it should be replaced every 3-4 months.
I called all the relevant parties. Kaiser had to have someone get back to me. The Kaiser representative told me that the feeding button was considered a prosthetic device, 'just like an artificial leg,' were his exact words. I explained that, no, a feeding button was not like an artificial leg because without the feeding button, Robert could not be fed and he would die. The Kaiser rep expressed some empathy for this possible outcome, but, alas, there was little he could do because we did not have a prosthetics rider. I argued the issue of 'medical necessity,' but he explained, without rancor, that 'medical necessity' did not matter if the item/procedure was not included in your plan. On the bright side, he pointed out that Kaiser covered the extension tubing for the button, as well as the syringes.
Then there was Cigna Healthcare. One of Roger's employers decided the Guardian plan, which was the best of all of our plans, was too expensive. So they switched to Cigna. And it was worse than that--Cigna covered all the regular employees, but the top executives were given a supplemental plan called 'ExecuCare,' which covered everything that Cigna didn't. Roger didn't quite make the cut of the very top executives, but knew some people who did (two companies merged), and discovered the existence of this 'ExecCare.' When we asked if we could pay both halves of the policy to be on it, we were told, no.
Why did we ask? Because this new company was relatively small, about 400 or so employees. When Cigna Sales discovered that they had been boondoggled into covering a disabled child, they realized that this lowered their profit margin rather dramatically. And the intimidation commenced. We had been assigned a case manager who was clearly a registered nurse. She called one day to say we'd been switched to another part of the case management system. The new case manager did not act like a registered nurse, although she claimed to be one; in fact, she behaved a lot like a collections agent.
Nurse Ratched proceeded to try to bully us into ceasing physical, occupational, and speech therapy for Robert, even though those had been prescribed by his physician. When we refused, she proceeded to verbally abuse our physical and speech therapists--actually screaming at them, and ending one conversation with the huffy statement, 'well, he doesn't need to learn to eat anyway, he has a g-tube.' When the therapists refused to back down, Cigna sales reps got involved. They claimed that the description of our plan that they had produced for distribution to the company's employees was wrong. Robert was only entitled to a total of something like 20 visits a year, combined, for all therapies (he went once a week). That was not what the paper said. I asked to see the version they were describing, which they said was kept at Cigna headquarters and was the official one. They said, no, we had no right to see it--only certain representatives of our employer could see it. Human resources got involved, but Cigna also refused to let them see the Top Secret Policy. While they were arguing, Cigna agreed to keep paying an extended number of claims for therapy, as stated in the document they gave me--I think it was about 60 combined per year.
In the meantime, they told us they wouldn't cover Robert's formula that went through his tube, they argued over everything they could, and they may have denied his medical supplies--it was a while ago and I can't remember some of the details.
And, in the meantime, Nurse Ratched started lying to me about therapy claims she'd filed with the main branch of our insurer. To be paid, the therapy visits had to be in our plan, I had to have a doctor's prescription and letter of medical necessity on file (both of which had to be renewed periodically, every six months, I think, with this plan), the provider had to submit a bill to Nurse Ratched, she had to approve it, and then she had to forward it to the main insurer for payment. She started randomly forwarding claims for payment. And telling me, as I went over dates of service that were not paid, actually spoke to her on the phone, that she had filed all of them with the main company.
If I had been most people, that would have worked. However, my father was in the military for many years--that means that, not only can I load a dishwasher and pack a car trunk with military precision, but I know better than to throw away any piece of paper related to a financial matter and I know how to create a complex filing system. I also have a PhD, so I can analyze an explanation of benefits form.
So the unpaid, randomly chosen claims started piling up. And the hospital got antsy, although they were very polite. And I kept calling Nurse Ratched, who kept lying to me. Every once in a while, I would try to call the main claims management line for Cigna, but, for the most part, that was staffed by apparent high school drop-outs.
This went on for about six months, and the bills kept piling up, and I kept collating them, stapling them, making notations about people I'd called and when and what time and what they'd said. I spent hours on this, but we were on the hook for a couple of thousand dollars.
When I was just about to give up, shortly before Roger was about to quit to start his own company (in large part because Cigna was determined that Robert would really be better off dead, or at least incapacitated), I dialed the main claims line. It was answered by someone I can only describe as an angel of mercy. She understood what I was talking about. I went through the bills with her one by one, for about two hours. She made notes. She said she thought something must be wrong on their end.
She checked. She called me back. Cigna would pay the claims. I just needed to fax the documentation, all 50 pages of it or so. I did.
A couple of weeks later, Nurse Ratched called my husband. It appeared she was in trouble, and she wanted him to call someone to tell that person what a good job she'd done. He laughed and hung up.
About six months after all of this was over, I was watching some kind of sports programming. Cigna Healthcare had arranged for several disabled children to go to some big sports event and skate and otherwise participate. The announcers were gushing about what a great insurer Cigna was and how much good they did. I sat down on the couch and sobbed.