08 Dec. 2009
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 "Explanation" of "Benefits"


<Fiction>My beautiful baby sister has been diagnosed with the extremely rare Ougadougou Syndrome, where she replaces the names of common household objects with African capitals and, sometimes, smaller cities.  This tragic disease has been very poorly researched, and only one drug company seems to have a cure.  They're running a trial right now where people with this syndrome can pay enormous amounts of money for an experimental drug that, the company hopes, will allow them to communicate normally.  Of course I've been trying to enroll her in the program, but the cost is prohibitive and my insurance company refuses to pay because the treatment is experimental.  I've pleaded with the insurance company, organized a group of people whose loved ones have this dreaded impairment, and engaged a lawyer to explore our options.  All, so far, to no avail.  I've been able so far to afford only one treatment, and although my sister received an infusion in her Nouakchott (as she put it), the effect was minimal and temporary.  A whole course, needed to (possibly) cure her, is unaffordable.</Fiction>


You've heard and read this story many times, with seemingly minor variations.  It's always something going wrong, and the evil insurance companies refusing to pay to make it right.  There's a reason for that, and by introduction to my own "explanation of benefits" I shall use my conservation-of-text button to incorporate this brief quote from my previous blogitem:

My Flu Shot

I am employed.  My employer provides health insurance.  I got a flu shot a week or so ago.  I was given a form to send in to get reimbursed for same.  I should get my payment back in due course. 

In case you've been wondering why the health care/insurance "system" in this country is so furshlugginer, the above paragraph says it most.  I'm waiting to see how long it takes to get reimbursed, and will probably expatiate further when I receive my "explanation of benefits."

A Minute Passed

Followed by about a month.  I received my "explanation of benefits," which, as I am fond of saying, is "three words, three lies."  Although turning "of" into a lie would require some Clintonian excess, consider it as a total phrase.  When I wrote the paragraph above, I fully expected one of two things to happen:
  • I would receive a check for my flu shot, or,
  • I would receive a statement that I wasn't getting reimbursed because our policy didn't cover the flu shot for whatever reason.
I am such a naf!  Either would have been so simple, and so not-insurance-company-like.  You can see I don't deal with these entities very much, or I would have immediately realized that they would instead have paid the wrong amount to the wrong party, which is exactly what did happen.  The insurance company decided that my flu shot, which cost me $30, was actually worth only $17.53.  And they decided to pay the company that administered the vaccine a lagniappe instead of sending it to me, who had already paid the company at the time I was immunized.  So I am now faced with a choice of tasks:
  • I can call the insurance company and complain that they reimbursed the wrong party.
  • I can do that and "appeal" the denial of the full amount as well.
  • I can call the company that presumably received the check that should have been sent to me, if I can track them down.
  • I can even (as was once done to me as a prank) call them both and conference them together and record for our future edification the confusion that results.  (Your call is important to us.  No, YOUR call is important to US.)

If I am lucky, after spending an hour or so doing this, I will recover my $17.53.  If I am really lucky, I might get my whole $30.  All in all, I think I'd rather write a blogitem.

The Problem with Health Care/Insurance

Perhaps the biggest problem is exemplified by the above heading.  Health care and health insurance are at least two different things, yet they are often merged in the public mind.  Health care is your blogger stopping for a moment at the gym to get a vaccination for seasonal influenza.  Health insurance deals with the bizarre aftermath when an expense I could (and should) have easily borne myself became the subject of reimbursement by those in the labyrinthine nexus of employer, employee, insurance company, provider, and your government in action.  Of course the insurance companies can't pay to remediate Ougadougou Syndrome.  They're spending all their money on my flu shot and your annual checkup.

Please consider this only a partial expatiation.  I may return to calculate the amount of money wasted by this process, and thus try to indicate the dimension of the problem and perhaps even suggest a solution.  Since I am a uniperson rather than two committees (a.k.a. "The Congress") I think I have a better shot at fixing it.  I'll be sure to send them all a link when I have done so, and I promise it will be fewer than 2000 pages.

"To Cry You A Song"
Jethro Tull




Everybody went to Oshkosh and all I got was this (admittedly very nice) shirt.

Cessna 172 T-shirt
Richard Factor

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