Tag Archive: medical cost


Rabbit holeHelp! I have fallen down the rabbit hole. My husband is self-employed and has insurance through the Health Insurance Marketplace.  We actually enrolled him during the initial roll out. There were no problems.  Signing up was quick and painless.  This year I received a letter, in my name, that we needed to resubmit his application through the government Marketplace. We wanted to carry the same policy.  Yikes! The only time I have ever encountered customer service this poor was dealing with disability insurance companies when filing a claim. Those of you following my blog know what that was like.

First I tried to renew through the website at 8:00 a.m. Everything went fine till the financial portion.  Because my husband is self-employed as a sole proprietor, he does not get a monthly paycheck.  The first question was asking the monthly income.  We base our income on the profit for the year before so I divided it int0 12 months. The same way I did it the year before. After completing this it said I had to send in a W2, pay stub, business ledger, or 2014 tax return. He is self-employed so he doesn’t get a W2 or a pay stub! I ought to copy our business ledger and send it to them, but I don’t want to kill that many trees or pay that much postage.  Obviously we don’t have a 2014 tax return. I gave up and decided to call the number provided.

It was now 8:45 a.m.  After a 10 minute hold time a very courteous young lady answered the call. She took all my information then told me she couldn’t discuss my husband’s insurance with me.   I reminded her that I received a letter to me for my husband’s insurance.  She absolutely would not, could not speak with me without my husband with me.  Thank you very much for the help. It was now 9:15 a.m.

Now for the biggest fiasco yet! At 9:30 I decided to try to call one more time and get another representative a try.  This time there was a 15 minute wait time. The call was answered by a young man that confidently responded that he could certainly help me with the task.  Everything went well till we got into the financial portion.  Once again he asked for the monshooting-starthly income and I explained the self-employment issue.  I stated our income hadn’t changed.  Finally after 2 hours going back and forth, we get his insurance set up for $325 a month.  But I still have to send in nonexistent paper work! Plus there is another number I have to call to get it started.  Wonder how long that will take? It  was now 11:35 a.m.

But it gets even better.  The same day I received a letter in the mail from my insurance company stating that if we didn’t renew it would automatically renew for $183 a month! If you saw a shooting star that night it was just the top of my head exploding!

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Here We Go Again

doctorMy private disability insurance policy from my former employer finally approved my long term disability payments.  The Social Security Administration, SSA, approved my disability coverage six months ago and ruled “disabled without hope for improvement.”  This means that SSA will not need to reevaluate my disability for five to seven years. After receiving one monthly payment from the private insurance, I received a call from their representative that I will need to be reevaluated due to criteria changes.  It is a wonder that I didn’t have a stroke right then.  I know my blood pressure must have been elevated because smoke was coming out my ears.

I don’t understand insurance companies.  Disability insurance is gambling, period.  The insurance companies are betting that you will not be disabled before reaching retirement at 65.  You are betting that you will be disabled.  In my case, I won the wager, but I have to prove that I won.  Unlike bookies that pay out winnings, insurance companies do not simply pay out winnings.  You must prove you won and guess who decides whether you proved it.  That’s right.  It’s the insurance company.  Even the law is on the side of insurance.

The Employee Retirement Income Security Act, ERISA, was passed by the U.S. Congress in 1974 and applies to most insurance obtained as an employee benefit. According to the website of Pillsbury & Levinson, LLP, ERISA is one of the worst and most poorly understood laws ever passed by Congress. ERISA gives insurance companies enormous advantages that may actually encourage them to deny claims unfairly.  It would appear there are no penalties for the insurance companies that deny benefits.  After 2 years, I am finally approved but must be re-evaluated because they changed their criteria.  The insurance companies can decide to change the requirements for disability at any time without notice to you.

US SenateUnder ERISA, a policyholder may NOT sue an insurance company for any damages caused by the wrongful denial of benefits no matter how egregious, outrageous, or malicious is the conduct of the insurance company.  Under ERISA there cannot be a jury trial, the policyholder must sue in federal court and there is no pretrial discovery.  If you sue the insurance company, under ERISA it must be filed in federal court and heard by a federal judge.  I had to go through this process in order to received short term disability from the same company that is providing long term benefits.  You do not get damages for the time without an income or the cost of filing the law suit.

ERISA covers retirement, health and other welfare benefit plans (e.g., life, disability and apprenticeship plans). Among other things, ERISA provides that those individuals who manage plans must meet certain standards of conduct,  detailed provisions for reporting to the government and disclosure to participants, assuring that plan funds are protected and that participants who qualify receive their benefits. As pointed out above, this law actually encourages abuse by insurance companies instead of assuring that qualified individuals receive benefits.

ERISA has also been expanded to include new health laws. The Affordable Care Act addressed pre-existing conditions, coverage of adult children, and other protections to ensure affordable health coverage for all.  The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) amended ERISA to provide for the continuation of health care coverage for employees and their beneficiaries (for a limited period of time) if certain events would otherwise result in a reduction in benefits.  The Health Insurance Portability and Accountability Act of 1996 (HIPAA) amended ERISA to make health care coverage more portable and secure for employees.

Wet cat

My benefits were reduced by the amount of my Social Security Act Disability funds so the amount to be paid by the insurance company is rather small.  They are supposed to pay for about eight years.  It appears that the eight years will consist of constant harassment, evaluations, and forms.  My employer paid for this benefit, but I wonder if the harassment will be worth it.

The really bad thing is that there isn’t a thing I can do about it. We are always told these laws are to protect us, but who do they actually protect!

I take methotrexate injections. My regular pharmacy is a large chain drug store and do not carry this drug. They said that it was no longer being manufactured. A small locally owned pharmacy had the drug and has been able to get more for me when needed. My insurance, however, will not pay for the drug because I am injected it on my own. If I went to a doctor’s office and they gave me the injection, the insurance would pay. This has caused me to wonder who is responsible and why this situation has developed. One can only decide that the insurance and pharmaceutical companies are primarily responsible, but politicians have allowed these companies to have total control.

Medication and syring

According to The American Society of Health-System Pharmacies these shortages were caused when manufacturers ceased production of the drug. APP Pharmaceuticals application to manufacture methotrexate has sat dormant since 2010. The New York Times reported there is a backlog of applications for new generic drugs at the F.D.A. because the government does not have the money to hire enough reviewers to analyze the applications or inspectors to visit the facilities. The generic drug industry proposed providing the agency with $299 million in annual fees to finance the review process as they grew tired of waiting for Congress to fully finance the F.D.A.’s generic drug office. Looking at the Food and Drug Administration’s website it would appear that current drug shortages are primarily generic drugs. The reasons listed are consistently either high demand or manufacturing delays. Could the true reason be greed? There is obviously more money in the brand name drugs than generic.

I have health insurance coverage with a major national insurer. This insurance will not cover my methotrexate unless I go to the doctor’s office and they give the injection. If I give myself the shot it works out to about two dollars a shot. If I went to the doctor’s office, it would cost much more. According to the online Health Affairs Journal physicians purchase products from wholesalers or directly from manufacturers, administer them to patients, and then charge insurers at prices much higher than those they paid. This practice undermines any insurer effort to extract volume price discounts from manufacturers. When accompanied by large price mark-ups, this gives financial incentives to physicians to prefer high-price, office-administered drugs over products that can be obtained through independent pharmacies. So I wonder who benefits from non-coverage of self-administered drugs.

So who is in charge of our health care and the drugs we need to stay healthy or even to live? Amy Klobuchar, US Senator has said that “over the past five years the number of life-saving drugs in shortage has increased dramatically – from 55 to 231 reported drug shortages in 2011. A female doctor This is a crisis that has grown to such proportions that current drug shortages have impacted individuals all across the country, forcing some patients to delay their lifesaving treatments or use unproven, less effective alternatives. In some cases, drug shortages have even resulted in patient deaths. This is a national public health crisis that must be addressed.” However, any government intervention in health care is met when fierce opposition. Why? We have had price controls and subsidies for milk, corn and soy beans. According to The Daily Caller, under current law, milk processors must pay a federally mandated minimum price for unprocessed milk. Where is the outrage over this government intrusion?

Our health is too important for government not to intervene. Of all the crisis we are facing as a country, insurance and pharmaceutical reform must be a top priority. If the health of our citizens fail, who will fight our wars? Who will lead our nation? Who will be able to work at a full-time job? Is the fox watching the hen house? Our representatives and senators seem to be listening to the insurance and pharmaceutical industry lobbyist more than they hear the private citizens. We are losing our voice as citizens. Voters have less influence than they do. It seems we need to speak louder.

Disability Dizzy

I bit the bullet and filed disability.  Boy, it is either the biggest mistake I have ever made or the best decision I ever made.  (Although actually I had no choice in the matter.)  The doctor had talked with me about disability.  Being the sensible and “level-headed” person I am, I said no I was better and could handle it.  As my husband would say, “I’m tough.” Well I tried for two months after the profusion to go to work and lead a normal life. At first it did seem somewhat better.  Soon the constant ringing in my ears made me put in earphones just to try to dampen sound.  I kept crackers and a coke beside me in my car if I became sick.  When I got home from work, I was exhausted and drained.

I elected to take short-term disability insurance.  The last company I worked for had disability sick leave. It was much easier to use and I often used it when I needed to rest and recover.  I assumed this worked the same way. I called the doctor who said that basically all that could be medically done had been done and I needed to file for disability. I made an appointment with the doctor but couldn’t get in for three weeks since it was not an emergency.  I filed the Family Medical Leave Act, which was approved with no problem.  The doctor signed and wrote a statement on both the FMLA forms and insurance forms the day after I filed.

The insurance claim manager had a problem with it as soon as she got it because she said I did not see the doctor the first day I stayed out of work. I had been sick two weekends in a row with nausea and ear aches.  Not to mention feeling like everything is leaning and moving.  When I could not go to work the second Monday I knew the time had come to file.  I didn’t go to the doctor because it wasn’t necessary.  We all knew it was the Meniere’s.

They requested the latest doctor’s notes and it was the week I was “level-headed”.  The notes say I had improved with only occasional dizziness.  Never again will I try to put on a good front!!  From now on I will tell it like it is.

Anyway, the insurance company turned me down. Said there was no proof I was sick on my last day of work.  Now the doctor will not release me to go back to work and the company I work for will not let me go back to work without it. Pardon me, but basically I am screwed.

Now there is an appeal process and of course, I had to get a lawyer.  Meanwhile I have to pay my bills. Thankfully, I had saved enough money for a few months.  Politicians like to say private insurance is better than social security.  I bet they don’t have the same company I have!

Good News Bad News

doctorGood news! My health is finally beginning to stabilize.  The methotraxate appears to be working and I am finally getting adjusted to it.  I go to the doctor next week so we will see what we see.  The bad news is the new insurance and health care cost are now my ailment.

My husband and I have to each meet the first $2500  as a deductible.  Since I had no clue who my employer would be 3 weeks before the contract changed there was no way to prepare for this.  My husband went to the doctor 3 weeks ago and an x-ray showed a mass in his left lung so a CT Scan was ordered.  Good news is that they think it was only pnuemonia.  Bad news is another CT Scan will have to be done to confirm that was indeed the case. More good news is that his deductible will be met.  Bad news we will owe over $1500.

I went to the dentist today and found out I need a crown.  Bad news is my new dental insurance only pays 50% of the crown or $450.00.  My goodness!!  It isn’t even gold!  Good news is I can use my health saving account.

There was a time when my finances were pretty comfortable.  Now when I should be looking toward retirement, I look for ways to pay our medical bills.  Good news is pretty soon we will both have met our $2500 deductible and won’t have to worry about it till next year.  Bad news is we have to save this year for next year.

None of this allows much room for putting aside extra for those rainy days.  I guess this is the rainy day.  At least I hope so. I seem to be working to pay medical bills. Don’t get me wrong, I want good health for both me and my husband.  But doesn’t it seem like maybe the medical system has us right where it wants us.  We don’t argue about the price.  We just pay it.  We don’t argue about the cost of insurance.  We just pay it.  We don’t negotiate.

The good news is that medicine is so advanced that we are living longer.  The bad news is that every penny we earn goes to pay for it.