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Healthy Insurance Part Two: Superheroes, Sugar, Smoke, and Scooters

March 17, 2010

Yesterday’s odyssey down the Hellish Brick Road that is the insurance industry yielded a few tips and pointers worth sharing. And, of course, a new batch of righteous indignation at the catastrophic clusterfuck that’s getting us all right in the ass. (Sorry, there’s no nice way to say it.)

First, I finally understand that the whole thing is a gamble. Every single thing about the insurance industry is based on odds. Insurance companies play the odds with the sole goal of spending as little money as possible. If you think they are there to keep you healthy, you are wrong. They are in business for the same reason everyone else is in business, to make money. And I don’t necessarily fault them for that, except that in this case, the stakes are human life and their methods make things worse for everyone. That, I have an issue with.

There is one gamble that many of you are taking, and need to stop taking, right now. Do you have uninsured motorist coverage on your car insurance? If you don’t know the answer, go find out, now. If you don’t have it, get it, now. That is a gamble not worth taking. It is an EXTRA on every car insurance policy. You have to ask for it. If you do not have it, and are hit by an uninsured motorist, you are very likely screwed. As would be the case with me, because the driver who hit us was not insured. The driver of the car I was in had uninsured motorist coverage that covered things for a while. It was only $10,000 worth of medical care, but that’s better than nothing.

Now, the other big gamble is the one that our Health Insurance companies take. Our policies, all of them, are filled with all sorts of coverage for all sorts of random things that we may or may not ever use. They’re there for us if we need them, and we pay for them, but more often then not, they go unused. Think of it as the ante that the companies place on the table. They never get called, they keep the chips. That’s one way that the house always wins.

There is no direct cash value for their gamble, but it is a strong starting point for negotiating an appeal about your coverage. When I spoke to the first agent at Premara Blue Cross of Seattle, she suggested that I ask them to take my 15 allowed days of residential physical rehab and turn it into 30 or even 60 treatment sessions of massage and physical therapy. Essentially, they have anteed up 15 days of residential rehab – which is thousands of dollars a day, and I don’t need or want. But if I called them on it, they’d have to pay. So I’m offering them a deal. You can keep your 15 days of in patient services, but give me 60 hours of outpatient treatment. It’ll cost them a lot less then if I called them on their bet, but they still don’t really have to do it. It’s just the right thing to do, which means they probably won’t do it. My gamble, however, is that I give up my right to those 15 days, if I were to need them this year. I’m willing to take that gamble. So we’ll see who’s bluff gets called.

I then went through my policy to see what else was in there that I could swap out in order to get the treatment that I actually need. I got confused almost immediately and decided to just call Premera and make them explain it to me, which is when things got really interesting.

Once again, I talked to someone who was incredibly nice and helpful. I cannot state enough that the problems in this industry are not the fault of the individuals who work in it, but the industry itself is such a huge giant mess. Blaming them would be like blaming soldiers for the war, so be nice to them.

I explained my whole saga to her and that I was trying to understand how to best appeal some of my coverage and make it useful to me. While she understood my swapping approach that was suggested by yesterdays’ customer service rep, she didn’t like the idea of me having to give up residential rehab, just in case. And suggested that my case should be escalated to some super secret sect of executives whose job is to evaluate special cases like mine.

What? There’s people who do that? I was shocked! She said something like, “oh ya, there’s a whole team that does that, they do so much to help, and no one knows about them.” I asked the obvious question, why does nobody know about them? “I don’t know! I didn’t even know about them until someone I know started working in that division. We’re really not even supposed to tell people about them.”

Seriously? Like they’re superheroes? I could picture them, in their swank but secret offices, with a radar screen honed in on pathetic me, writhing in pain, a darling heroine in need of rescue (my boobs are bigger and hair curlier when I picture it.) They would tear off their suits to reveal stockings and fab abs, and fly to my rescue. I love them. My service rep, in her sweet way, starts making calls and asking questions preparing to ship my case to the Super Ones. I picture her as an elf, tiny and diligent. I am momentarily happy.

I asked her how my case got escalated and she said, “well, it’s a crazy case, but you’re also just very nice.” There ya have it kids. It’s not done or anything, but you catch more superheroes with sugar.

I explain to her that what I need is very simple. MRI, CT Scan, massage and PT. If we do it right, this will take less than a year, be inexpensive and simple. If we ignore it, it could be catastrophic and expensive. “I know,” she says, “isn’t it crazy, you’d think they’d just want to deal with problems before they were problems.”

“Besides,” I say, “if I were an obese smoker, you guys would give me a scooter for free.” “Don’t get me started,” she says, “I really can’t comment on that.” But it’s true.

Which is the final part of the insurance gamble that we need to think about. The biggest gamble that insurance companies take is that there will be enough healthy people like me paying into the system so that they can cover the expenses of the fat smokers. I sort of hate to demonize one population of people, but it’s so easy in this case. And necessary.

The CDC  reports that the direct cost of treating smoking related illness is $96 billion a year. In 2000, the total cost of obesity in the United States was estimated to be $117 billion-$61 billion for direct medical costs and $56 billion for indirect costs.

You know who pays for that? You and me. We do it in our insurance premiums – healthy people offset the cost of sick people. We do, with our tax dollars that pay for the public health systems that cover un and underinsured people.

Why does that piss me off? Because it is a lifestyle choice. And it has nothing to do with getting healthy. The fact that insurance will provide a scooter – something that ultimately makes the problems of obesity worse – to someone who is making a lifestyle choice to be sick, not healthy, is just wrong. I’d be more than happy to pay for a personal trainer, a gym membership, even healthful food, all of which would help solve the problem. But not something that makes a the problem worse.

To me, this is a lot like saying, “we will not cover the treatment to fix your broken neck that you got in a car accident, but we’d be happy to pay to put you in traffic so you can get hit again.”

So there ya have it for the day. And here’s what you need to do:

1. Make sure you have uninsured motorist coverage on you car insurance.
2. Understand your health insurance coverage. Find out what you pay for in your coverage and figure out how to use it. Also, understand the limits, how it works. It is totally worth calling your provider and just understanding your policy.
3. Please get involved in the healthcare reform debate. And let’s work together to make it about health, not keeping people sick and the industry even sicker (and twisteder.)

Next installment, smoke. What happens when a super-healthy fitness freak bursts into tears when her doctor explains the litany of pharmaceuticals she could take to relieve the pain, actually saying she could take the, “Rush Limbaugh” route. Medical Marijuana, that’s what happens. I’m glad I live in Washington State.

___

This is part two of a series. If you want the background, read part one.

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