Health Insurance 03/12/2010
 
The United States is facing a health care crisis.  This sentiment seems to be accepted by everyone regardless of political affiliation. 

In my practice, I see evidence of the crisis everyday.  Earlier this week, I was working on a case where my client has a $115,000 hospital bill.  We tried to get his health insurance (provided through his very well respected Christian employer) to pay the bill.   The insurer denied coverage beyond the $450 they had already paid claiming my client had reached his maximum benefit under the policy.

My client paid approximately $70/mo for the coverage made available to him by his employer.  The coverage has $100 deductibles, no RX coverage, and $15 co-pays for regular office visits.  It's maximum annual benefit is $1,000. 

Under the policy, if the employee has a $1,600 ER visit, the policy will pay 80% of the balance after the $100 deductible is paid ($1,200) and the employee will pay the remaining 20% ($300).  Of course, the employee will have paid (or will pay) premiums for 12 months in the amount of $840 in addition to the $100 deductible and the $300.  The employee will have paid $1,240 (towards the ER visit and the premium) and will still owe $200 because the maximum benefit is $1,000 - not $1,200 (80% of the bill after the deductible).  If the employee has any other healthcare needs (other than a regular office visit), he will have no additional health insurance coverage until the following year.

In light of the insurer's denial,  how much of the $115,000 ER bill do you think will get paid now?  Who will pay for it?  Will it affect future health insurance rates?

This is a policy provided by a highly respected Texas employer.  By offering the coverage, the employer can say that it offers health coverage as a benefit to its employees.  In my opinion, the policy is more of a fraudulent scam - at the very least the insuring agreement is unconscionable.

When large highly respected employers begin offering these types of policies to their employees and pass them off as "health insurance," we have a crisis!  Sweeping changes are necessary.  It is of no benefit to our wonderful country for party partisanship to prevent us from addressing the issue.  Rather than bicker about one side's proposal, there must be a concerted effort to suggest alternative reasonable "sweeping" changes to our healthcare system.

A patchwork of suggested remedies will not fix the problem.  Keep in mind, the most likely reason large employers offers "health insurance policies" such as the one described above, is to manage costs.  Insurers have made coverage more and more restrictive while continuously raising rates.  Exclusions (and other limitations for coverage) and rates must be addressed collectively.
 
 


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