The Lion's Den

A friend was recently laid off her job after nine years of employment. These things happen even in a good economy and even to good employees; it’s life. She filed for unemployment, is looking for a new job, enrolled for classes at the local junior college and is otherwise proactively dealing with this major upheaval in her life. She is 38, she’s healthy and her husband is self-employed. Since she received her family’s health insurance through her employer, they are now in need of their own plan.

She was turned down due to a pre-existing condition. Allergies. Yes, allergies. Nothing exotic, mind you. No lethal food allergies; she doesn’t have to avoid peanuts or shellfish. She is not going to go into anaphylactic shock over some esoteric medication - no, we’re talking about plain old hay fever. A dangerous pre-existing condition if there ever was one. It is only but a symptom of the general meltdown in our health-care system.

Although there are far too many issues, both global and specific, to enumerate here, there is an overarching unfairness to how the alliances fall out. There are essentially three players in the game: The caregivers (doctors, hospitals, etc.), the insurance company and the patient. Although there is an almost sacred relationship between the doctor and patient and certainly an economic relationship between the insurance company and its customer, these alliances both crumble when it comes to who is legally responsible for paying the bill.

Stories circulate about how doctors and other caregivers are bound by the insurance companies in what they can and cannot do. They would have us believe that the three-piece suits dwelling in glass towers dictate their every move. Conversely, the insurance industry tells of the sky-rocketing cost of medical care and that they will surely go broke if they can’t somehow control their costs. Neither the caregiver nor the insurance company wants us to know that they enjoy a symbiotic relationship; that they are on the same side; it is really these two powerhouses versus the patient.

Blue Cross of California recently settled a class action lawsuit because it was refusing, without cause, to pay the claims of its customers. It is one of many lawsuits against insurance companies. Blue Cross had no trouble paying it. They still won. Even after the legal expenses and after the payouts to their “customers,” Blue Cross is still doing just fine, thank you very much. They’re holding all the cards, along with the doctors and hospitals and the supporting cast, this alliance is in the business of collecting money - from you. And they are good at it.

Because the patient holds the ultimate legal responsibility to pay for his or her medical bills regardless of whatever insurance coverage is in effect, the insurance company can afford to drag it’s feet when it comes to paying; the bill collectors are not coming after them. Someone pays the caregivers eventually - insurance (after two, three or more billings), the patient who can afford it (often paying what the insurance company should have but didn’t), by inflating the costs to everyone else and finally by the taxpayers. The insurance industry collects premiums from you and then actively avoids - successfully - ever paying for your care. And these two players are playing the game all day every day.

The “responsible” party is the newcomer. The patient comes in as prey. Wandering into the lion’s den often already wounded by a catastrophic accident or illness, the patient does not know the rules or even that there is a game. He or she is expecting the insurance company to uphold its contract and the doctors to provide the best possible care no matter what the cost. Foolish patient! The ultimate responsibility is theirs and often the cold hard reality comes far too late. As long as the responsibility party is the weakest player in the game, the patient will continue to lose.