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.
Love the site, I wonder if your relative has a cause of action against her employer/ins co/state ins board, as she was never provided a copy of the plan but was told she had “health insurance” as a benefit. It seems that someone was negligent in that process and had she been adequately informed maybe she’d have had major medical insurance or been on her husband’s plan… You may want to encourage her to have an attorney draft some letters, what does she have to lose? We had Aetna in Medical school…couldn’t even use it at the non indigent hospitals I worked in, until the student gov’t forced the school to change it.
id agree. if she really wasnt informed and wasnt given any literature, i would pursue this. This type of medical insurance needs to go away. It really doesnt provide any significant coverage and gives people a false sense of security.
That is also disgusting about the medical school. Frankly they could self insure the students if they wanted to (at a reasonable cost to the students).
So what’s your opinion about businesses receiving tax breaks because they offer insurance to their employees? This is a perfect example of a great idea gone terribly wrong. Instead of businesses paying their employees fair salaries and giving them the responsibility to find the best coverage for their needs, businesses get tax rewards for pigeonholing their employees into plans. They can’t buy outside of the employer because prices are insanely high (more a reflection on the flawed tax structure and lack of interstate competition than the free market). Honestly, you should read the insurance policy of the company you are interviewing, because once you get there, that’s all you get.
I agree with you Mark. A historical accident resulted in our dysfunctional insurance/health care system. It all came about from government-imposed salary controls after World War II. You couldn’t pay your employees more, but you could offer them benefits like health insurance. It’s like the toaster thing with bank accounts in the 70s. You couldn’t pay a decent rate but you could give away toasters.