There is an oft-quoted saying that many Americans are just one bad illness away from poverty. Believe me when I say, I never thought that would be me. Two years ago, I was 33; I had a Green M.B.A., had just started my own business, and was buying my first house, thanks to an inheritance I used for the down payment. I felt miles ahead of most 33-year olds.
Last summer, though, oil prices skyrocketed, our government signed off on the bailout, the real estate bubble burst, and I was diagnosed with Stage IIIA breast cancer. In less than three months, I was closing my business, trying to sell a house for just over my mortgage (losing my entire down payment), and unemployable thanks to a challenging chemo schedule and multiple surgeries. At least, I told myself, I have health insurance.
The week after I finished chemo, I received my first claim rejection from MEGA Life and Health Insurance, an independent health plan marketed by the National Association for the Self-Employed (NASE). NASE reps tout the benefits of membership – $40 a month – which gives members access to premium-quality, “low” cost insurance – about $120 a month for me (strangely, my premium went up $40 after my cancer diagnosis). Comparing the benefits to the crappy Blue Cross insurance I had before ($1200 was my “negotiated rate” for an emergency room visit), it seemed like a really good deal, especially when I listened to the NASE rep’s glowing review of the way the company handled his wife’s hysterectomy. I thought I was in good hands.
It was only after I got sick that I found out MEGA has a $1,000-per-day cap on chemo treatments, and that they would deny the claim for my lumpectomy based on the fact that I had a benign “breast mass” a year prior to being insured – the logical equivalent of not covering someone’s appendectomy surgery because they had a perfectly healthy appendix before their effective coverage date! Fortunately, a call to MEGA to remind them that I had two mammograms and two sonograms that showed nothing but healthy tissue for two years prior to my diagnosis got them to “check into the matter.” They came back and said it was an error on their part, and that the denial was actually for extra days in the hospital following my lumpectomy, which were not covered in my plan. I then quoted Rosa DeLauro’s Breast Cancer Patient Protection Act, passed in September of 2008, which prohibits insurers from denying benefits when physicians recommend extra days post-surgery. They put me on hold again, then assured me they would re-process the claim in 7-14 days.
I understand that many insurance companies reject expensive claims as part of their Standard Operating Procedure, in the hope that some patients just won’t be smart enough or diligent enough to fight back. When this happens, doctors lose money, and patients are stuck with bills they can’t pay, paving the way to financial ruin or at least destroyed credit. How is this okay? How does a company justify routinely not delivering what they promise? When you go to a store and buy a suit, are the cashiers routinely instructed to leave the pants out of your bag to save money, in the hopes that you won’t notice and say, “Hey, you told me this suit came with pants?!” How is that an okay way to do business?!
When insurers started dictating treatment based on increasing profit margins, medicine stopped being effective. Since when is it acceptable for someone to be told, “We’re absolutely aware that your doctor thinks you need this to stay healthy, but we’re recommending a lower-priced option to increase the amount of money WE’RE making off your illness”?! Medicine is not Manufacturing! We need a treatment and profit model that has, as its highest goal, the improved health of the American people, and not the improved coffers of the insurance industry. Let’s hope that Congress, and President Obama, recognizes that the drivers need to change if we’re going to turn this car around.
April Capil, host of http://www.aprilcapil.com
April blogs about cancer at http://teamapril.blogspot.com. You can find her on Twitter as @aprilcapil
