THEIR RULES, OUR PAIN

Real stories of people trampled by the insurance companies

"My PPO, which "covers" me and my husband, costs nearly $500 a month ($6,000 a year), with a $3,000 deductible for each of us. After the deductible, we have to pay $30 for a regular doctor visit and $50 for a specialist visit. Last fall, I spent a great deal of time appealing denied claims for labs and treatments for a UTI and then a bad yeast infection, and ended up paying most of what was supposed to be covered myself, so it did not count toward my deductible.

"After that experience, when I fractured several ribs in a running accident I didn't even bother to go to the doctor. Then I fractured my elbow and had to go because, unlike ribs, these bones do not heal themselves. I found that my expensive (at least I think it is) plan covered (with my copayments) the office visits and the X-rays, and would have covered a heavy plaster cast that I couldn't face wearing. It wouldn't cover the removable splint that took the therapist all of half an hour to construct from a piece of steam-heated medical plastic and some glued-on Velcro straps. I had to pay $1,200 myself for that. Then I found out that my plan would cover not a single session of physical therapy, even though my shoulder, arm, elbow, and hand, all of them riddled with scar tissue, would remain useless to the end of my days without it. Apparently, physical therapy is not considered a medical necessity for someone who can only afford $500-a-month premiums. And so I have been paying for that too."

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Mrs. H's experience illustrates the problem perfectly. There's no good information to compare insurance policies, so you can't make an informed choice. You'll never know what treatments and tests your insurance will cover or what they'll pay until you need them because the insurers won't tell you and they don't have to.

We need the government to set the rules on behalf of all of us. We need wholesale bulk pricing. That's how we get the leverage to bring down costs and ensure everyone has the coverage they need. So long as we are on our own, we're stuck with skyrocketing retail prices and denials of care when people need it most. Like 17-year-old Nataline Sarkisyan, who died after her insurance plan denied coverage for the liver transplant her doctors recommended.

Blocking or denying legitimate claims is a common industry practice.

Learn more about the insurance industry's Foul Play.

Read other stories in the "Their Rules, Our Pain" archive.