Ask the Insurance Warrior
5/15/07

Q: I have good insurance. I am not planning to need experimental treatment. Why would I need the Insurance Warrior?

A: My message is so much bigger than "experimental" treatments.

This book speaks to everyone with any kind of health insurance who ever comes down with ANYTHING EXPENSIVE. Health insurers are denying treatments/surgeries/medications which you thought were covered. Think you are insured? Think again. Your health insurer has dozens of ways of not-paying which you have never dreamed of.

You have seen the quote from Readers Digest: "Between 2000 and 2003, seven in ten adults who were driven into debt by medical expenses had insurance at the time."

Say what? You are more likely to face financial ruin from medical expenses if the HAVE health insurance than if you don't have it. How could this be?

With the advent of "managed care" back in the 1970's, the health insurance industry took sweeping steps to control skyrocketing costs. (Gee, how well has that worked?) They came up with the brilliant idea of having doctors work for the insurance company, and to task them with controlling costs by controlling access to services. Holy cow! Is this a scary conflict of interest or what? Your doctor may be fined, penalized, or otherwise sanctioned just for referring you to a specialist.

How do you know if your doctor is recommending something because it will help cure you, or because the insurance company will pay for it?

My doctors here in Seattle didn't say, "We won't pay for experimental treatment." They said ...

"There IS no treatment for your disease."
"It is slow-growing, don't worry about it."
"You don't HAVE cancer."
"If you go to this expert of yours, you will be disabled."

When I was first diagnosed with cancer, friends often asked me questions designed to make themselves feel safe. They wanted to know for sure that THEY would never get cancer, never be surprised by cancer, never have their lives turned upside-down.

Same deal with health insurance. "Oh, I will never have a problem, because I have good insurance," "I will never get cancer," "I will never get a rare disease that needs special treatment."

If you ever get anything expensive in this lifetime, you can look forward to a huge fight with your insurer. They have dozens of secret ways of not-paying ... from the day you meet with your doctor, to the day they finally pay -- if they pay -- and reduce reimbursement.

Sometimes I feel like Paul Revere out here: "The insurance companies are coming!" What we really have these days is a very thin veneer of coverage. The health insurers have a word for this: Cost Shifting. Shifting the costs to us ... very big costs. Could be millions, charged directly to you.


A few examples. Every one of these people thought they were covered.

The man in Massachusetts who prompted the newspaper article about the Insurance Warrior. He had cancer, his insurer didn't want to pay for his medication. It wasn't experimental ... they just didn't want to pay for it.

You have prescription coverage, you are safe, yes? Wrong. Every health insurer has a "formulary." The formulary is the list of medications that they will pay for. If it is not on the list, they will not pay for it. Guess which drugs are NOT on the formulary? The most expensive ones, and the most commonly-prescribed ones.

A couple here in the Northwest, in their sixties. They have the most expensive, bells-and-whistles health insurance. They are covered, yes? Well, she comes down with brain cancer. The only drug for her type of brain cancer costs $16,000 per month. The insurer doesn't pay for it, it's not on the list, too bad for you. Last time I checked, they had run through their entire retirement savings, and had lost their home.

Which brings me to my next example ...

A very nice man in the Midwest with an incurable testicular cancer. The only treatment that is keeping him going costs $1,500 per week. His insurance is paying just fine. Then, a few months ago, there was an open enrollment where he could apply for Medicare Plan B. He asked his insurer -- twice -- "Do I need to apply for Medicare Plan B, or will you keep paying for my treatment?" No problem, they said, we will pay as we always have.

Guess what? The next time he went for his treatment, the Explanation of Benefits said, "Zero Pay." The reason? You should have applied for Medicare Plan B. Since Medicare would be paid for it, we won't pay for it. Guess what else? He can't apply for Medicare Plan B again until July 2008.

He spent a few months suffering, and missing his treatments, and calling the "Rapid Response Resolution Team" who never called him back. Then, he Googled and found me. I wrote a seriously scary letter, he got it to the right people, and it took them less than a week to decide to pay until he can bet accepted for Medicare Plan B.

No ... it's not just about experimental. It's about anyone who ever has to USE their health insurance