I have a family member in her 50s who was recently diagnosed with metastatic pancreas cancer. She presented with painless jaundice, a pancreatic head mass was seen on CT, a biliary stent was placed, and at ex-lap a small metastasis was seen on the liver so a gastrojejunostomy, cholecystectomy, and an alcohol neurolysis of the splanchnic nerves was done instead of a Whipple.
I’ve been trying to help her navigate the medical maze she has been thrust into. She has employer-provided health insurance about which she originally said, “Oh yeah, I’ve got really good health insurance.” But when she went to get her first Gemzar treatment, she was informed that her insurance wouldn’t cover it (and that the cost would be about $15K a month). I couldn’t believe it was possible to have a health insurance policy that didn’t cover chemotherapy, so I actually called her insurance company and got a copy of it. I was appalled.
This “health insurance” has the following limitations:
- 10 physician visits per year
- $100 per visit for up to 3 ED visits (this is the maximum payment, NOT the deductible)
- $1000 in surgery or diagnostic tests per year
- $50 per month in outpatient prescriptions
- $400 per day (up to 15 days per year) for inpatient hospitalizations (same rate for ICU admissions)
The policy is quite clear, when you read it, that this isn’t a “comprehensive” policy and that if you get really sick, it isn’t going to cover anywhere near the entire cost. But who reads their health insurance policy? She was never even given a copy of it. It took me, a physician, 45 minutes on the phone in 3 separate phone calls and 10 minutes on the web just to find the policy. (It took almost as long to find my own.)
Most employees don’t read these policies. I’m furious with the employer, since I assume he actually did read this policy, and intentionally decided to screw over his employees by telling them they had “health insurance” when in reality, they didn’t. And I’m furious that the state insurance commission actually allowed this policy to be sold without appropriate disclosure that it wasn’t real health insurance. Obamacare outlaws policies like this starting this year, but apparently Aetna was able to get a waiver for this particular policy for 2012.
The first thing I did after reading her policy was go find my own. It’s a HDHP with a $3000 deductible and a maximum $5000 out of pocket per year. My employer combines that with a Health Reimbursement Account that essentially lowers my deductible to $500. But the policy covers everything you’d expect it to, including many types of reconstructive surgery and certainly chemotherapy.
I’ve been lucky to have always had a good health insurance policy. I was on my father’s plan through college, which was negotiated by a state employees union (you better believe they read their health insurance policy.) I bought an individual policy in med school (but luckily never needed it) and then had a good policy in residency (my first child cost $10 total) and then a $0 deductible for four years in the military (my second and third children were free.)
When was the last time you read your policy? How about the one you provide for your employees? I suggest you go read it BEFORE someone gets sick. Just like with disability insurance, you might need an individual policy despite having a group policy through your employer. If you aren’t insured against medical catastrophes, you run the risk of facing the choice my family member now faces- relying on charity care or declaring bankruptcy. Even with Medicare, Medicaid, cash discounts, non-profit hospital charity programs, and manufacturer assistance programs, there is still a gaping hole that never should have existed in this safety net. It’s a real tragedy that someone working a real full-time job, whose husband works a real full-time job, doesn’t have the insurance coverage she needs now that she is sick.