Being Insured in America

Last I heard, there are about 45 million Americans going about their daily lives without health insurance. Each and every day, these folks put their livelihoods on the line by hoping that their health doesn't take a turn for the worse. And if it does, whether by freak accident, illness, or any number of possibilities, in addition to the jolt to their health, there is a good chance that they'll incur medical bills that can never be repaid. And as a result, the rest of their lives will be spent buried under bill after bill.

But what about those who are covered? What about the middle and lower class of America? What are the real benefits of being covered? The majority of us really don't know what's covered until we're faced with a condition that requires medical assistance. And then it's often one very large gray area; a reality that is the basis for the US health care business model. In other words, who knows?

A few years ago I had an ailment that required me to see a physician on repeat visits. Knowing that I'd be returning on a number of occasions, I phoned my health care provider, Blue Cross, to inform them of this. I was told that I did not need approval from my primary care doctor and was assured that I was covered. After a few visits, I submitted my claims. Weeks went by and nothing. And then months. I then submitted my second round of claims. Again, nothing. I then spent an entire morning speaking with various folks at Blue Cross asking about my claims. Each person provided a different story: still being processed, can't find the claims, you will hear shortly, not covered, covered. It was as if there were five or six possible responses and each person chose a different page in the manual.

A few more weeks passed when I suddenly received my first denial. A few days later, denial number two arrived. I called again. Repeat scenario above. Growing increasingly frustrated, I went to my human resources representative. Thankfully, this person went at this task with the same steadfastness as I did. She was relentless in her attempts to get answers. But nothing changed. Then, in a last ditch effort to get to the bottom, my company enlisted an intermediary between ourselves and the insurance company. I spoke to the intermediary, had doctor's vouch for everything, submitted all the paperwork again and spent hours on end on the phone.

One week later I received a check for about $1,400. What I've outlines above is only part of what it took to receive payment. How many insured Americans would go through these steps in order to receive payment? My guess: less than 10%. Most would understandably toss in the towel and bid that cash farewell; cash that is rightfully theirs.

I later joined another company and my insurance moved from Blue Cross to Blue Shield. And once again, same issues. But this time I just didn't have it in me to take on the fight. I won the first go-round, but just didn't have the energy. Claims were denied and I let them go. Then I just stopped submitting.

In late-October I lost my job. Given that the bi-weekly paycheck ended, for kicks, I decided to submit a claim. And just today I received the following: This service is specifically excluded from coverage under the subscriber's Blue Shield plan. Wow, that's not what I read when I reviewed our plan. That's not what I was told when a Blue Sheild rep. came to our office and I inquired about our benefits. But as I said above, this is how insurance companies work. They ultimately want to exhaust you. They want to frustrate you so much that you just give up. And then your money is theirs. And the most laughable aspect of this all is that I'm now paying $322/month out of pocket for this "insurance".

As I typed that final sentence, the following line streamed through my computer speakers: "What it all comes down to, is a different set of values." It sure does.