For many people, health insurance premiums take a sizable bite out of their paychecks. Which would be somewhat tolerable if insurance companies did anything to ease the process of actually receiving medical care. Heck, most of us would tolerate the pricey payments if insurers just did the bare minimum of what they are supposed to do and didn’t put up roadblocks to getting the proper care. And yet that simple concept appears to be too complicated for some insurance providers to grasp.
Take this story from David Lazarus’ column in the L.A. Times about a father who has spent a year and a half dealing with nearly incomprehensible levels of idiocy at Aetna, as the insurance company repeatedly tried to force his daughter to get care at a clinic that doesn’t provide the care she needs.
The father in the Times story has a daughter with autism. He also has an Aetna policy that is supposed to cover 20 visits a year to the occupational therapy his daughter’s doctor prescribed in Feb. 2011, so long as the therapy is provided at an in-network clinic.
Aetna signed off on therapy at a nearby clinic, but then the father discovers that this clinic does not provide the specific treatment prescribed by his daughter’s neurologist.
Thus he went back to Aetna for the name of another clinic.
Aetna told him to go back to the clinic.
The father wrote Aetna a letter trying to explain what they had obviously ignored — that this clinic is not the correct one for his daughter.
Aetna once again told him to take his daughter to that first clinic, where she won’t get the care she needs.
It gets better/worse (depending on your tolerance for repetition).
The father went back to the clinic. He got a letter from the doctors there explaining that they could not help the young girl. He asked Aetna once again for a new referral.
And he got one. To the same exact clinic.
The father, who subsequently went out of pocket to the tune of $120/session for an out-of-network clinic that could provide the therapy his daughter needs, filed a complaint with the California Dept. of Managed Care, since state law now requires insurance providers to cover prescribed occupational therapy for children with autism.
In order to legally dispute the issue — and per the terms of his Aetna policy — he filed for arbitration with the American Arbitration Association. When the arbitrators made the standard request for Aetna to waive the provision of its contract limiting the amount of damages that can be awarded to customers, the insurance company didn’t respond. This bought the arbitration process to a halt.
But investigators for the state didn’t look so kindly on the insurance company, saying that Aetna had “either ignored or disregarded” the father’s attempts to correctly follow the company’s own referral procedures. The state found that Aetna had made no attempt determine whether the original in-network clinic could provide the prescribed therapy.
The state ordered Aetna to pay for the father’s out-of-pocket expenses and to continue paying for treatments at this second clinic through 2012.
A rep for Aetna tells Lazarus that — in spite of multiple attempts by the father to clearly point out that the first clinic could not help his daughter — the insurer “originally did not understand the nature of the dispute.”
The rep also tried to point the Flaming Arrow of Blame (patent pending) at the father, telling Lazarus that the dad must not have followed the referral process correctly. Yeah… state officials have already deemed that claim “factually inaccurate.”
In many ways, Aetna’s insistence on the original clinic is not very different than some phone CSR for a cable company telling you to reset your modem for the fifth time while you’re trying to explain to them that there’s a severed cable dangling in your backyard.
But while you can always cancel your cable — you’ll survive without the History Channel — most people have no such options with their insurance provider. Cutting cable out of your life will only put more money in your pocket; getting rid of your health insurance only serves to make treatment more expensive, and all but guarantees you won’t receive the level of care you would if you had coverage.
Insurance companies may not be required to pretend they care about our well-being, but they are required to do their jobs correctly. For the money Aetna and other insurers make, it’s not asking too much.