The health insurance blues, Part I

If you’re anything like my father, what I’m about to say will put a chill into you: From the age of 22 to 37 my wife and I didn’t have health insurance. And although a risk, I can honestly say it was the best money never spent. Granted, those were the carefree days of young adulthood where health concerns were of little worry, but ever since getting health insurance three years ago, I’ve never been more scared in my life that something will go wrong. And this is not a case of superstition. I’m not worried that now that I have health insurance I’ll get sick.

I am worried, however, about dealing with health insurance.

I fully admit that I was a supporter of Obamacare and the subsequent Marketplace when it was established in 2014. Before then, getting health insurance was simply an impossibility for my wife and I. Before the Sun Day, I worked jobs that didn’t offer those benefits, and after starting the Sun Day, the only insurance available was either buying our own (which didn’t cover pregnancy) or buying a corporate package and insuring us through it. Either way, you had to pay through the nose. We simply couldn’t afford it. So when the Marketplace was formed, we finally had our opportunity. Lackluster plans (with laughable coverage) and tax penalties be damned, it got us to where we needed to go. It got us our son.

What follows is a two-part series, displaying the woes of navigating the healthcare system, which I have to say is broken—bad—and insurance companies are still running as rampant as ever.

When my son was born, he was covered under my wife’s insurance for the first 31 days, as is the case with most newborn coverage, so when my son was transported from Centegra Hospital Huntley to Rockford Memorial Hospital under emergency circumstances the day after he was born, we assumed (and were told by various hospital staff) that his care would be covered. About a month after his release from Rockford Memorial Hospital’s NICU, we received a bill from RMH for over $25,000. My heart literally dropped into my stomach then my stomach just fell out of me. Upon closer inspection, I saw that BlueCross BlueShield did pick up $19,000, but we were still left with about $7,000 of charges between his care at Centegra and Rockford’s NICUs.

When I called BCBS to inquire about the charges, I was told a number of reasons why the claim wasn’t covered in full, the primary reason being that RMH was out of my wife’s policy’s network. I then pointed out that her policy clearly states that in an emergency, no matter if the hospital is in network or out, the claim is covered one hundred percent, so long as the out-of-pocket maximum was met, which my wife’s was from going through the care associated with pregnancy and delivery. I was then informed that didn’t apply because my wife was released separately from my son. Note: don’t even try to make sense of this because it makes no sense, and I was never given a straight explanation.

Moving on.

Getting nowhere with BCBS directly, I used the health insurance mediation program through the office of Lisa Madigan, who inquired directly with BCBS on our behalf. After nearly a year of communication with BCBS, it was finally explained to us that, yes, according to my wife’s policy, emergencies were covered one hundred percent, but my son’s care, even though deemed an emergency, didn’t qualify because, well, I’ll let BCBS explain it. According to their official response:

Emergency medical care is defined as the initial outpatient treatment of a medical condition displaying itself by acute symptoms of sufficient severity such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonable (I think they meant “reasonably”) expect that the absence of immediate medical attention could result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Cole’s treatment was provided as inpatient, not outpatient, so it would not meet the definition of emergency medical care.

So basically what they’re saying is that since a doctor deemed his care a medical emergency it was downgraded to just extended care, but if he was at home and we, his parents, deemed it an emergency, then it would have been covered. So when a doctor deems a condition an emergency it’s not an emergency, but when a layperson deems it one, it is. Maybe it’s just me, but you’d think it the other way around.

Had I known this at the time, I would have had the doctors discharge my son, walked him out the door, then turned around and walked him back into the emergency room.

Editor’s note: the topics discussed in this column and the next are not politically charged. I’m not insinuating a presidential preference or supporting any political party over the other. I’m simply stating that there’s an issue with our health-coverage system that needs to addressed. Also, information on the mediation services offered by the Illinois Attorney General can be found by visiting illinoisattorneygeneral.gov

---

---