I'm having my first real negative experience with a health insurance company. Given the documentaries, first hand experiences, and the nightly news, I've always felt it was just matter of when, not if, I would have my own story to tell. Well, the answer is February of 2014.
In October I woke up with a dull throbbing pain a tooth that had no business being in pain. I'd had a full root canal on that particular tooth ten years ago and since that procedure involves physically removing the nerves that communicated pain to the brain, I was surprised to say the least. Had the nerves returned? And more importantly, were they pissed?
It was a Saturday and the pain began to get worse. I called my regular dentist and this being New York, they were too booked to see me. I needed help. It was becoming an emergency. I crowdsourced an answer on FB and found a website about self-treating a toothache at home. One of the things suggested was to floss either side of the tooth to see if some debris might be causing the discomfort. "Why not?" I figured. I looped the floss around my fingers and when I brought it down between the offending teeth, it was if I struck myself in the face with a white hot lightning bolt of pain. My eyes flashed open, I saw the unfamiliar look of horror on the face of my reflection and realized what I would look like in an internment camp if someone were to shove bamboo under my fingernails. It was as if someone had taken a sharp steak night and stabbed my jaw. I saw a flash of white light and my knees gave out. I collapsed to the bathroom floor.
"OK, so the whole 'try flossing!' approach has failed, what next?", I thought as I propped up myself on the toilet. Luckily, I had enough friends on Facebook that were able to help me get to a dentist who took a look, took a poke, quickly diagnosed that I had an infected abscess under the tooth, gave me a scrip for antibiotics, and told me to come back to see an oral surgeon in the coming week.
The oral surgeon assessed the situation and said, "Unfortunately, not all root canals work forever. You have space between the tooth and the gum, probably a crack in the crown and tooth itself, and essentially what needs to happen is that the tooth needs to be removed and replaced with an implant. That means the tooth comes out, we do some bone grafting, and then add an implant. The good news is that an implant is strong, sturdy, and should last for the rest of your life." I nodded along listening to his diagnosis and assessment of the situation. I wasn't crazy to have to have another invasive surgery inside my face, but hey, whatever the Doc says. He's the one who knows best.
So I headed up and talked to the scheduling and billing person. I told him I wanted to find out how much of the procedure that my Cigna Dental Insurance covered so I could have an idea of what the financial impact was going to be before we got going on multiple surgeries. He said he'd check in with Cigna and get back to me. A few weeks later I got a postcard in the mail from my dentist proclaiming, "GOOD NEWS! You're covered! It's time to schedule your procedure!" Interesting way to convey the news. I called the office and spoke to the business affairs guy and said, "Great that I'm covered. So what's going to be the damage?" He called up my file and said, "Yes. So....good news and bad news. Cigna will pay for the extraction of the bad tooth, so 50% of that extraction is covered. But, they won't cover the bone graft or the implant." All of a sudden the "GOOD NEWS!" post card seemed a little misleading. After finding out that the breakdown is essentially $275 for the tooth to come out, $696 for the bone graft, and $1600 for the implant. So the total number we're talking about is $2570. I told the guy I wasn't going to schedule or go forward with the procedure until I figured out what was going on.
I called Cigna and got on the line with a customer service rep who called up my file and we talked through what the issue was. This is where things start to get profoundly interesting. The Cigna rep told me that indeed, Cigna does not cover implants. "But..." I said, "That's what my dentist said I should have. And your my dental insurance." Beat. "Yes, but we don't cover implants." I inhaled and furrowd my brow. "I'll bite. Why not?" The Cigna rep then said, "Because there are other, less expensive procedures to treat your particular condition." I said, "Oh, really? That's great. What are they?" He said, "You could get a bridge or a partial denture." I said, "Hold on." while I just did a quick Google search to discover that both the bridge and denture options are antiquated, potentially dangerous, need to be replaced every ten years, compromise neighboring teeth, make clicking sounds, fall out, and just kind of all around SUCK. I expressed that to the Cigna rep who said, "Yes, but they are cheaper procedures and address the issue." I said, "How much is a bridge or denture?" He looked it up and said, "$1500". I said, "And Cigna covers how much of the procedure?" He said, "50%." I said, "We, we're talking about a difference of $50 for Cigna." There was silence. "Well, this is ridiculous.", I said to a man who probably was trained on day one of his 'job' to hear fucked over patients say. "Just to clarify. I have paid $750 for my dental insurance that only has a maximum pay out of $2000 anyway. So it's not so much insurance as a Groupon. But nevertheless, it's something. So you only cover 50% of a surgery like this. But you're telling me that you won't cover 50% of the procedure my doctor recommends. So I've paid $750 that I could have put towards this procedure if I'd chosen NOT to have dental insurance?" Beat. "Well, sir, you actually have a pretty good plan." I said, "Listen, I know you're just a guy with a job. But it's a pretty bad job. I would hate to have to be you, telling people they can't have the care their doctors recommend because I'm employed by a mercenary insurance company that puts profits over care. We're done for now. Thanks for all of your help, but man, if I were you, I would find another job. I don't know how your soul can take it."
When I got off the phone I realized that I was joining the ranks of thousands and thousands of people who are screwed over by their insurance companies every year. Earlier this year my mother had knee replacement surgery in both knees. She was put in a rehabilitation center after leaving the hospital until she was able to get safely home. As her progress was made, her doctors recommended that she stay until the Tuesday following her surgery. Friday, she was called by her insurance company and informed that they would only be paying for her stay until the following day, Saturday. When she asked why, the insurance company said, "Because we have access to your charts and you've hit certain benchmarks that indicate you're able to leave." Again, the doctors, who are experts, and had SEEN my mothers' legs and her progress recommended she stay until Tuesday. But the insurance company, who are not medical experts and hadn't been anywhere near my mother, cut her off Friday night. And that's just my family We're just a microcosm of what's happening out there.
It's also comical to me that insurance companies are allowed to make these determinations. I would think that part of the way the contracts are negotiated between hospitals, patients, and providers would be that what the doctors says is what will be DONE. I mean, unspool what happened with me. To get a bridge would mean shaving down and compromising other teeth for a crappy bridge that would need to be replaced in ten years. A partial denture doesn't protect against bone loss in my jaw and I could end up with facial collapse. Seriously. It'd be like someone breaking their leg in five places and instead of paying for an intense reconstructive surgery, the insurance company saying, "We'll pay for three bottles of whiskey and some crutches." How do we allow insurance companies to determine what care a patient gets based on what they'd like to pay for?
Dispirited and angry, I turned to the only recourse I felt that I had, Social Networking. I wrote a scathing Facebook message and began tweeting. Surprisingly, the power of Twitter is ample. Within an hour of tweeting about @Cigna, I had them pleading with me to contact a customer service specialist. I wrote to the email provided by Twitter and was introduced to "Nicholas" who assured me that he would do everything in his power to be my "advocate" in this case.
Already I felt as if I'd fallen down a rabbit hole. Who was Nicholas and how, as an employee of the very company that had essentially just told me to 'eat shit', would he help me not have to eat shit? I suspected it would come to naught, but I said, "OK. What are we going to do?" Nicholas told me he would help me with an appeal process and sent me some paperwork to fill out. From November until two days ago, I went back and forth between my dentists' office, oral surgeon, and insurance company in a circuitous spiral of emails, documents, pdf attachments, x-rays, and more to move through the Cigna appeals process.
I think I actually came up with an interesting and startling revelation in my research for the appeals process. I was actually arguing to SAVE Cigna money. Here are the last two paragraphs of my appeal letter...
"My prime objective is to get coverage for the procedure with the highest likelihood of a positive outcome for my health and well-being. For Cigna, I understand that keeping costs down is the primary objective. The evidence seems to suggest that my surgeons’ recommendations and Cigna’s objectives are actually in concert with each other. In the case of a denture, Cigna would have to pay for replacements every five to ten years and potentially have to provide coverage for jaw destruction and facial collapse. In the case of a bridge, Cigna would also have to provide coverage for replacements every five to ten years. Additionally with a bridge Cigna exposes itself to cost risks by endangering adjacent teeth to decay, root canal, and other expensive covered procedures. Since the failure rate of an implant is less than 5% and will last a lifetime, strengthen the bone in my jaw, and require no replacements or maintenance, analysis would seem to suggest that this in the best financial interest of Cigna. The most current testimony, research, and testing suggests that in the long run Cigna’s best financial decision also happens to be covering the procedures my oral surgeon has recommended.
Given the circumstances, I feel that the expected outcome of this appeal should be that Cigna provide the amount of coverage that it would have provided for either a denture or bridge procedure, with the difference being covered by me. My research into the matter seems to suggest that this is a fair outcome, given that the plan participant can more easily get the procedure recommended by their surgeon while the insurance company is not paying out more than they would have for the procedures that they do cover. Given that in the long run, my health and Cigna’s bottom line are both most favorably looked after by my receiving a dental implant, then I should be covered to some degree for that procedure."
I thought I'd argued my point fairly well. I wasn't asking for a dime more than they would have paid for the inferior procedures. After months of what in retrospect was clearly stalling, I heard back from Cigna that the appeals board has denied my appeal. Imagine my surprise. Oh, yeah, you'd have to imagine my surprise because it was the least surprising thing that's ever happened in the history of planet Earth. Now what's truly hilarious is that I don't know if there even IS an appeals board. I never heard from them. I don't know who they are. I received no letter, no paperwork, no reasoning, no explanation of the board's decision. Just an email from my "advocate" Nicholas telling me, "Sorry I couldn't help you achieve a more favorable outcome." I don't even know Nicholas's last name. As far as I know, there's no appeals board, just Nicholas, the customer service "advocate" listening to Michael McDonald CDs, eating peanuts, and luring me further and further down the rabbit hole to placate and distract me for as long as possible before simply hammering home their initial decision to deny me the care my doctor recommends and that I've PAID for. In that case, there's really a kind of perversity involved; that they hold out hope from some internal appeals board that may or may not exist.
So here I am, right back where I started. I've resumed my Twitter complaining campaign. I'm going to try to get New York State involved in a third party arbitration which may compel Cigna to provide some sort of care. I'm writing this blog post. I'm telling my story. I'm not going to suffer in silence. And I don't think anyone else should either. I think so many of the problems we face as people, we imagine to be unique to our own lives and so we suffer in silence. But they are too common. These things happen all day every day and the only way they will change is when a critical mass of people stand up, tell their story, and we realize that we're all in this world together and we need to take care of each other.
I think about the recent reforms in Health Care and I'm profoundly unhappy with them. I don't think a program that compels Americans to get insurance from private health insurance companies that participate in the kind of amoral behavior, like that I've described above, is the answer to our health care problems. Ultimately, there is a clear conflict of interest at work here. If health insurance companies are traded on the stock market and operate on the profit motive, then it behooves them to do everything in their power to raise premiums and deny care. Take the premiums. Deny the care. I know it's more complex than that. I've been following this issue since 2009 and Obama's taking up the issue as his legacy initiative. But in my opinion, there is no culprit more culpable for the pain, suffering, and deaths of thousands of people in this country than health insurance companies denying coverage to the very people who have paid for that coverage.
I honestly don't know how we have arrived in 2014 as a United States of America without single payer Universal Healthcare. I think when people are frightened by the talking points about America being in danger of adopting "European-Style Socialism", they don't know what European-Style Socialism is. The happiest people on earth are the Danish who are taxed at a rate of 75%. And you know what that tax rate buys them? It buys excellent and equal education for everyone all the way through college. It buys immaculately clean and healthy cities. It buys months of guaranteed paid vacation. It buys a year off when a baby is born. And most humanely, it buy absolutely Universal health care. In most parts of Europe, if you are sick, you get treatment. Period. And a cursory google search will reinforce what Single Payer advocates have been saying for years. In this country, we pay more for health insurance and get less for it.
But the way that politicians sell us on NOT getting Universal Single Payer is that it would raise taxes. Well, what if we switched out the word "premiums" for the word "taxes"? I mean, you have to pay for health insurance one way or another, right? Whether they're called "taxes" or "premiums", it's money out of your pocket (or your employers) for a service. But you know what the difference between premiums and taxes is? The money you spend in taxes DO something. They pay for police, roads, regulations, food safety, and more. And if you do the research (PLEASE DO), you see that in the countries with Universal Health Care, those taxes pay for excellent and effective paper-work free care that doesn't let people die or bankrupt them. The money you pay for "premiums" in my case and in the case of thousands of others, often does nothing. It's money flushed down the toilet. Well, for me. For Cigna it's money in the bank and certainly helps their CEO maintain his 12.5 million dollar a year salary. The government isn't trying to turn a profit or pay for the lifestyle of a millionaire CEO. It's trying to provide a necessary service. A health insurance company is trying to make money and the best way to do that is NOT give you what you've paid for. It's cold, hard capitalism and it doesn't care if you live or die. I vote for taxes over premiums. You?
In the founding documents of this country our revolutionary brothers and sisters codified in a Declaration of Independence that we are endowed by our creator with certain inalienable rights and that among them are, "Life, Liberty, and The Pursuit Of Happiness" It's seems self-evident to me that it's impossible to have liberty of pursue happiness if you're Life is compromised by denied care or you're thrown into personal bankruptcy by an unexpected illness. I maintain that any health-care system governed by the profit motive is out of touch with the contract that we could and should have with each other in a country as abundantly prosperous as ours. We are all in this life together. We are fellow citizens of this great and noble country. We should take care of each other. I hope one day soon we will undergo a fundamental shift in our national priorities and that when we do, we will come to the conclusion that we are better Americans, better citizens, and better human beings when we educate ourselves, help each other, and do that most very human of all human things; Care for each other when we are ill.
HEALTH CARE IS A HUMAN RIGHT