My Health Insurance Company Wants Me To Be Unhealthy
It was New Year’s Eve 2016, and I had 394 running miles for the year. I’ve always been a little bit of a numbers guy, so it bugged me that I might end the year that close to 400 and not make it. So I left work a little bit early, and set out to run the last six miles. The run was great, I felt strong, nothing out of the ordinary.
But after my first few runs of 2017 I noticed an increasing pain in my left knee. I get pains from time to time of course, but this was different, something was up. Long story short, I went to an orthopedic doctor and the MRI clearly showed a meniscus tear on the inside of my left knee. I was going to need surgery.
Mind you, I had surgery on my right knee 20 years earlier, but at least that time it was very obvious how I did it. I had an epic mountain bike crash, gravity sucks. This time I wasn’t even sure what happened! The doc depressingly informed me that I’m not 25 anymore and I can now tear my meniscus by apparently just sneezing, or perhaps brushing my teeth too vigorously. Age happens.
He was also clear that I could forgo the surgery and “just not run anymore”, since it didn’t hurt when walking or doing normal day to day activities. But as a good doctor who also has a 3:05 marathon to his name, I could see it in his face that he was thinking “this isn’t good advice but I’m obliged to tell him” when he was saying that. I deliberately went to a sports focused orthopedic surgeon for that reason, and he knew the score.
Not run anymore? Ha, that’s funny. You’re cute, now get out the knife and let’s get on with it.
Cut Me Mick
I scheduled the surgery quickly to ensure I’d be recovered before the weather warmed up. He assured me that I’d be back up and running about 6 weeks after the operation, and on my bike as soon as a few days afterwards. In the grand scheme of things it was a very minor surgery. But he also reminded me “there’s no such thing as routine surgery”, meaning things could go wrong. I was going to be put under, which has it’s own risks. And the risk of internal infection when foreign instruments go inside you is always a thing.
He literally said “I’ll be inside your knee for 10 minutes, maybe 15 tops”.
He was right. The surgery event as a whole took about 4 hours, but three of those four hours were waiting, filling out paperwork, and laying there in a gown watching horrendous morning TV, waiting to get the show started. Between the time the anesthesiologist came in and knocked me out to my wake up and exit from the operating room was maybe 45 minutes to an hour.
I’ll say this up front, my Doc was awesome and the entire procedure was great. Everyone was top-notch and professional. They even offered me a lollipop.
Then started the fun.
We’re Here To Insure You, On Our Terms
My fear of the expected health insurance “faux bills” and incomprehensible notices came true. Every 3 or 4 days I’d get a cryptic letter from my insurance in the mail with labels like “uncovered balance” and dollar amount in thousands next to it.
They told me before the surgery that my share would be a $175 copay, and everything else would be covered. This of course was only after a tussle with them, but more on that later.
One Of The Offending “non-bills”, $1456 “not payable by plan”
#DoesEnglishEvenMeanAnythingAnymore?
Letter after letter would arrive with a “not payable by plan” column and an amount around $1000 or $2000 next to it. I’d call my insurer and ask why this was.
Insurer: “Oh, hmmmm….. just ignore it”
Me: “Well then why am I getting these?”
Bueller?…… crickets……
After 8 or 9 of these letters piled up, the total of the threatening claims implied I would owe about $8,000.
“Ignore them”
Sure. That’s easy. Having super-megacorp send you a bunch of letters claiming you owe them $8000 shouldn’t be stressful at all. Nope. Because if and when they screw this up, I of course have a massive team of high paid lawyers ready to defeat them and get my claim settled properly. Yeah, move on. Nothing to see here.
No sweat. No stress.
What a ridiculous cluster.
In the end, I paid my $175 and it worked out. At least I think. It’s been about a year now but it wouldn’t surprise me to still get a bill. This is the circus sideshow that is health insurance in America.
How much did the full surgery cost overall?
$12,500!!
This, my beloved reader, is why I’m semi-retired and not fully FIRE’d from my main job.
You Gotta Fight, For Your Right…
But let’s backtrack a bit – we haven’t even gotten to the fun part. My insurance wasn’t initially going to cover the surgery at all! They claimed it was a “degenerative” meniscus tear versus one that’s caused by a trauma or accident. And oh, “we don’t cover those.”
So here’s the deal. At the risk of bragging and sounding like a cocky douche, I’m going to brag a bit and probably sound like a cocky douche. I’m the picture of health at my age. I’m their best customer! I have 12% body fat, a resting heart rate of 46, and I can rattle off five or six 7-minute miles. In a row. I ride my bikes 5 or 6 thousand miles a year, run four or five hundred miles, and eat super healthy. I enter bike races with kids in their 20’s, and beat many of them. (douchy part over, sorry… despite all that I’m the poster child for a weekend hack at sports.)
So I get a meniscus tear and they say “we’re not going to cover it.”
Awesome. I’m a very healthy customer who barely ever goes to the doctor but keeps giving them tons of money. I rarely ever have a claim! And now I can’t run, and I need a $12,500 surgery. However, they apparently would rather have me stop running and doing all of the healthy activities that I do, gain weight, and become fat!!
Noooow I see their business strategy!! They’d rather have me unhealthy and charging them more money for more doctor visits! It all makes sense now….. Sheeesh, how could I be so business-illiterate and not see this brilliant plan! Sure, it’s a bit “out of the box” thinking, but I like their weirdness and eccentricity.
This is total Twilight Zone stuff people.
I still get worked up when I think about it. (takes break, makes ginger tea to settle stomach…)
To top it off, at the bottom of these threatening non-bills they were sending me, they have the nerve to put this:
Yeah Sure, Be Active. Except We’re Not Going To Cover Your Broken Knee Because, Ya Know…. Reasons.
#WhyCan’tYouBeActiveWithYourDamagedKnee? #DidWeSaySomethingContradictory? #IsTheEarthRoundOrFlat? #WhereTheF*ckAreWe? #WalkingCanesAreAllTheRageTheseDays #WeDontCoverTheCostOfTheCane
In the end, I yelled and threatened enough to win, and they covered the surgery. I was ready to go all Rambo on them.
If you’re a new reader, I’m financially independent. But I’m only semi-retired because as indefensible as this healthcare situation is I’m far more fearful of going out to the wild west of the ACA and all the coming political madness around its future existence. To me that’s the epitome of high risk.
$12500 for a minor surgery. My dad died of cancer in the late 1980s and even back then the bills were in the hundreds of thousands. Our insurance covered most of it, but what’s to stop any of these companies from proclaiming cancer as “degenerative” and just flipping you the middle finger (and correct me if I’m wrong, but isn’t the whole body degenerative after a certain age!?)
Yeah, they have more lawyers than we do.
To me, healthcare concerns are by far the #1 risk to an early retiree, or any retiree. No other aspect of life has the potential of bankrupting you at the blink of an eye through no fault of your own.
None of us knows what’s in our future regarding our health. Fate can deal anyone a horrible accident or terminal disease. If you’ve spent time on my blog you know that I encourage everyone to take care of their body as much as possible. A large portion of your health is in your control. Don’t eat crappy food, exercise, and take care of the only body you will ever get. To me that’s an understood responsibility in life.
But some of our health is out of our control. Many of use have drawn a bad genetic card, and will only find out when the card decides to show itself. Others will get into an accident or get injured through no fault of their own. Still more are born with a major health problem and will live their entire lives struggling to cope.
So I beg you to take a long and hard look at your plan for health coverage if you’re an aspiring retiree. Do your research, assess your risk tolerance, and consider your options. Don’t let the crazy cost of healthcare be your downfall.
Me? Even though I’m financially independent, I’m staying semi-retired for now.
Your Turn – Do you have a crazy healthcare story to tell? Does your insurance company want you to stay injured too? Please share!
It’s sad how normal this is. Our system is broken. There are 2 major problems that your case demonstrates and they’re why I see little to no hope for the system being fixed.
1.) Many people love the ACA because it doesn’t allow discriminating against pre-existing conditions, but they don’t understand what this means. In ways, this is good. My mom is a breast CA survivor and small business owner who has had to buy her own insurance until reaching Medicare age this year. Prior to ACA, insurance was ridiculous. On the other hand, every other type of insurance is able to control costs by incentivizing desired behaviors. Get in a wreck or get a speeding ticket? Car insurance premiums rise. File a claim on your home? Homeowners premiums rise. Eat horrible food, never exercise, and become obese and diabetic? Doesn’t matter, costs the same as you who takes care of yourself. Illegal drugs? STDs? Excessive alcohol? None of it matters. The only way health insurance can discriminate is cigarette smoking (why that is singled out I don’t know) and age. It’s absurd, and we who try to live healthy lives are all left subsidizing these unhealthy behaviors that drive up costs. And no one wants to have real conversations b/c everything is so politicized.
2.) The system is impossible to navigate. We try to control our costs, especially now that we have a high deductible plan, by shopping around and there is no pricing transparency. My wife recently needed a routine diagnostic ultrasound. Costs among 3 local providers ranged from about $200-$500 for the exact same test within a 15 mile radius, and it took hours of sitting on hold and multiple phone calls with each place just to get a price. Then once she finally got it done, she still got buried with the multiple bills, statements that are not bills, etc. We are still getting them a couple months later, and she was not charged what she was supposed to have been. We’re both young & educated, and I worked in health care for over 15 years and we can’t navigate the system. How is someone who is elderly, uneducated, etc supposed to do it.
I agree with your assessment that way too many people underestimate how damaging a negative event could have on their finances. It’s sad that you feel trapped by health care after reaching FI, but I don’t think you’re being overly cautious. I think you’re being smart.
Wow, thanks for the thoughtful comment Chris and you make some excellent points. It is indeed true that the healthy are subsidizing the unhealthy in a big way. And on top of it, the healthy are a shrinking minority as the country continues to become more overweight and obese. Type-2 diabetes is rampant and will only get worse.
And it seems you and your wife received the same non-bill threats that I did. I consider it intimidation, whether it’s intended that way or not. It could just be bureaucratic incompetence, but either way it sucks.
I don’t have the answers to fix it, it’s above my pay grade, but something needs to be done.
First of all, I love the humor in your writing. You can take a somewhat dry subject and have me cracking up! I totally agree with you too. The healthcare business, and it is a business, runs off constantly sick people, which is why they do not, IMHO, work on patients to change lifestyle, and/or get to other reasons a patient might be having trouble in an area. It’s crazy! And yes, bills can come much much later if they want to. It’s like the insurance office is bored and they throw a dart at a picture of a patient to see who they can charge more this month. 🙂
THANK YOU Tonya, that compliment means a lot! Especially from someone who makes some damn funny videos! And we’re in violent agreement – what we need is a medical system that works with people to be healthy, not just treat them when they get sick. I know more about fitness and diet than some of my doctors, or at least the latest/greatest research.
Love the comment about throwing darts too, I can totally see them doing that!
The insurance business is very opaque and short sighted. We providers are always tussling with them also.
I think Docs like yourself need to form a pact or union and unite against these damn companies. Y’all have a lot of power 😉
That’s horrible. They created so much stress. So why did all those bills go away? The insurance worked it out? I’d be so stressed out if they tell me to just ignore them. I can’t ignore those things.
I’m worried about healthcare too. My wife is still working so we’re okay for now. Once she retires in a few years, then healthcare will be a big issues for us. Hopefully ACA will still be around. Or else, we’ll probably go for medical tourism for non life threatening stuff.
The bills” went away I guess because they were non-bills. They would say on them “this is not a bill”, but at the same time they have a column that says “not payable by plan” – always with a substantial dollar amount. So what am I supposed to make of it!? It’s just nuts.
Good luck with it Joe, you should definitely ride out your wife’s employer plan as long as you can.
Healthcare in this country is the worst. I got hit by a car on my bike and I’ve been dealing with it for 18 months. They want me to re imburse their expenses.
Oh that’s after they denied to pay for vaccines because they are considered a luxury.
I HATE HEALTH INSURANCE!
I remember reading about your crash, sorry to hear you’re still dealing with the mess but I’m not surprised at all of course. And vaccines are a luxury, HA, good one. So not getting measles or mumps is like buying a Gucci bag? Nice world they live in
Wow Joes right, this is good!! Bless your hashtags. Why did they sent you those bills if you were covered? Those are like mini heart attacks on paper….ohhhhh yeah okay that makes sense.
Sometimes I get hashtag-inspired 😉 They sent those non-bills in my opinion as an intimidation or because the system is so opaque and mysterious that they’re all just incompetent. Either way it sucks. Mini-heart attacks on paper – love it. Yeah, they won’t cover that!!
So, one of my friend’s boyfriend works as a contractor for a health insurance company. His job is to send denial letters — to everyone, every time. As he tells it, many people see these letters and just fold and pay the bill. That makes me crazy and I can’t believe he does this as a job. It’s sad that this entire health insurance issue is a major reason people like you are FI, but still unwilling to completely retire.
I agree with Tonya. You have such a great entertaining way to look at this huge problem. #WalkingCanesAreAllTheRageTheseDays! Hey, I think your health insurance company is going to sponsor a walking cane half-marathon in your area soon. Better start training now.
What a horrible job to have!!! I wonder if he feels bad about himself when he goes home? I could never do that, I’d feel like scum.
Yes, canes are the schizzle!!! It used to be walkers, but then the bearded hipsters made canes ‘a thing’. After canes get too popular they’ll move on to crutches, or “artisanal crutches” 😉
i was sick a few months ago and i work for a megacorp. this was real sick, like a flu or something, laid up in the house sweating and sleeping for 4 days, so i went to the doc for some antibiotics. after day 3 out from work our employees now must check in with a henchman type company to verify the illness as stated. well the henchman company then harassed my doctor who told them she didn’t excuse me from work (she didn’t). i excused myself because i was bedridden and sick! i have rarely missed time in my 14 years here and did the right thing by staying home. the bottom line is that my illness could not be pinpointed and couldn’t have a nice neat code printed next to it so the henchman company 400 miles from here attempted to deny my sick days and asked if wanted excused time or vacation time. it’s a good thing i couldn’t reach through the phone and choke the living bejesus out of that hench-claims-person. i’m still ripping mad even though it was overturned by our plant medical staff (yes, we have that). it seems now you must go into a doctor visit with a strategy for explaining yourself ahead of time. “i don’t know, i was f’ing sick!!!! i hope you get the opportunity to have an unknown illness and talk to somebody like you some day. that would be marvelous, don’t you think?” i could go on, but now you’ve made me upset.
Oh lord, sorry to hear that Freddy. That’s effing ridiculous! You’ve barely been sick in 14 years and they have the gall to challenge how you say you feel!? Sounds like some folks at the henchman company need a kick in the teeth. I couldn’t imagine having a job like that – critically questioning people who say they are sick. I’d dig ditches in a cemetery before I did that
oh, and they sent me a survey a few weeks after my “case” was “resolved.” i showed restraint and deleted it.
Practice stoicism my friend, you’re the better person 😉
I know you said that this was the “bad advice” option, but how is not doing anything about it advice at all? Wouldn’t it just get worse over time and eventually maybe it WOULD hurt during normal activities? Or is that now how meniscus tears work?
Also, I have a special hatred for insurance companies. Mine tried to charge me a whole boatload of money because they didn’t realize that I had TWO babies at the same time and denied all the hospital’s claims for the second baby as “duplicate”. Like they’ve never heard of twins before. Insurance companies are the worst.
Meniscus tears in what’s called the “white zone” of the meniscus do not heal on their own since they do not get blood circulation. That was my tear, according to the doctor. He couldn’t predict if it would get worse over time, my assumption is that much of that would depend on my lifestyle and how I use my knee.
HA – they categorize twins as ‘duplicates’, that’s a new one. They’ll try anything. Thanks for the comment.
You already know my crazy health story, and I definitely had to pay more than $175 for less satisfying results. But let’s get back to the back to back 7 minute miles – in my freaking dreams! Incredible.
Yes your story sucks worse, but you’re handling it in a more mature way than I probably would have.
As for the running, to be clear, doing 7 minute miles is not my training pace, that’s my full-bore race pace. That hurts. My 5 mile PR is right around 35 minutes and that’s leaving it all out on the road and ending up nauseous. My goal used to be to get it below 7 minutes but I’ve had that goal for years now and haven’t accomplished it. Age is not on my side 😉
It’s been a full year, so I’ve had time to process. Though there are still days I still yell about the unfairness of it all, but ultimately, it is what it is, so I may as well learn how to live with it.
What’s your average “just going for a run” pace these days?
Man, life does deal unfair cards. But you and your husband are so “together” with your money and your future that there’s nothing you won’t be able to handle.
I do most of my runs at about an 8:30 pace. Now that it’s heating up that probably slips to 8:45 – 9:00. I don’t handle the heat well, I’m a prolific sweater. I kid you not, on a 90 degree day I can lose 3lbs of water in sweat on a 3 or 4 mile run. We have an accurate digital scale at my office and I check it, it’s common.
And we’re together on the hearing loss as well 😂
I’m glad you can take a lighthearted approach to a very heavy and infuriating topic, your hashtags had me laughing out loud! #Wedontcoverthecostofthecane lolol … but for reals, this is my #1 fear, now and all years in the future. I feel like our healthcare setting is just one big game of Russian roulette, every year. Would love to see a world without the middle men where healthcare is transparent (as Mr. Groovy wrote about: http://freedomisgroovy.com/should-medical-tourism-be-on-your-radar/) but have 1% hope of that happening in my lifetime, or by the time I’d need it…
One big game of Russian roulette – you just nailed it! That could have been my whole post and I could’ve saved a ton of words.
And you can see Doc G’s comment above about how opaque the industry is – and he’s smack in the middle of it. It just sucks all around. The best we can do is keep sharing knowledge online like we are and find the best path together based on collective experiences.
Thanks for the comment!
I am truly confused by the health care in your country. I’m sorry you had to go through all that!
All of us Americans are confused about it. And for those who aren’t confused and worried, well, they’re probably the ones getting fat off of it.
Thanks for stopping by and reading!
Man what a story, the current health system definitely is scary. I guess that’s what happens with a privatized system.. they want you to be unhealthy as you will pay them more and they’ll get more profit!
Loved the “you’re their perfect customer rant” it’s so true!
Sometimes ya gotta rant 😉
You’re such a cocky douche 😏. Nice read bud.
Thanks for the compliment!!
As a NP, working in the ER, then in-patient Medical Rehab, then Oncology – I’ve seen the insanity of health insurance/health “care” up close and personal. I’m traveling. I’m going to self fund while traveling because other countries don’t bankrupt their citizens when caring for emergencies. I will have a travel policy for catastrophic stuff. I’m going to stay as healthy as possible with activity, occasional fasting, and good clean food. I can’t control everything and even having insurance won’t save anyone from financial ruin when people who have no business making health care decisions are doing that every single day. I don’t think I can afford to live in this country full time until I qualify for Medicare. I doubt I’ll ever find another position that offers insurance to me because although I’m a provider – most jobs in my field are 1099 contracted positions. It’s all so effed up I can’t even think about for long because I start feeling as powerless as I did when I was working for a hospital with great benefits. One thing I know for sure, the golden handcuffs I was wearing because of insurance was not worth the trade for my sanity. Great post!
Wow, coming from someone in the healthcare industry like yourself, that “bleakness” doesn’t give me any warm fuzzies that we have hope of fixing it anytime soon. And you’re correct, insurance does not in any way shape or form protect one from ruin over a healthcare issue. If anything it probably just gives a false sense of hope…
Wow, great inspiring story. I don’t have any similar issue to address, however, do keep up the great work, will re-visit often!
Thanks for the compliment!
Not fun. I enjoy running on occasion. Couldn’t imagine dealing with this.
Some food for thought: often times, hospitals and specialists will play a coding game with insurance companies, and patients get caught in the middle. The hospital/physician rarely looks bad, because they can just send you their bill directly without remorse. The insurance company inevitably winds up being the bad guy because the chop shop didn’t submit the claim properly. In your case – if the physician had submitted the right diagnosis code, there’d be little to argue about your reimbursement. Insurance co’s have to go with what the doc submits.
Not letting insurance co’s off the hook – but it’s important that everyone understand that bad actors exist on the hospital/physician side as well. They’re out to pile up as much cash as the coverage guys, if not more so. And more often than they’d like to admit, they F it up in the claim processing and prior authorization process.
I’ve heard of what you’re talking about with codes, and yes, I know that docs and hospitals can sometimes be bad actors. I’ve heard they also push for too many diagnostic tests to meet quotas etc. I don’t know how to fix stuff like that but there’s gotta be a way. It is a complex problem. Thanks for the comment man!
Um, but have you tried being more active and maybe taking the stairs every now and then? It all counts! 😉
Health insurance is such a terrifying situation. Hell, even with a fantastic employer-sponsored plan it’s still terrifying. Every time we have our annual open enrollment meeting I have to wonder if this is the year our good plan finally got too expensive for them to cover so now we’re either going to have to pay a ton out of pocket or switch to a worse plan. Or both. It shouldn’t be that way.
It should not be that way at all. Hopefully we’ll see a real change in our lifetimes
Thanks for sharing.
While, not nearly to the scale as some of the other folks that have commented. I have experienced frustration with the health care system and insurance providers. We recently had our 2nd child and what a nightmare trying to figure out the billings and co-pays. We were still receiving bills after 9 months!
I haven’t had a ton of problems or exposure, but from what I’ve seen I couldn’t agree more with the article. Thanks!
9 months is ridiculous…. and if you’re like me those bills make you nervous, it’s a stress-point.
Great post! that triggered me a question: …why do you live in the USA and didn’t move to Countries with universal health care ?
Honestly I don’t understand FIRE living in the USA being a such unfriendly country for retirees
Because I’m an American, all my friends and family are here, and mostly because I love my country. That one flaw is relatively minor in the grand scheme of things considering everything else America is and offers.