THE BLOG
08/20/2013 08:13 am ET Updated Oct 20, 2013

Even if You Have Health Insurance, You May Not Have Health Insurance

Health insurance companies are a lot like friends; you never know what they're really like until the chips are down.

Odds are, if you've never had a serious reason to call on your "friends" at your health insurance company, you're still "buddy buddy." But, God forbid you ever end up needing them, you may end up waiting by the phone.

My insurance company, and I, were BFF's for years. And, why shouldn't we have been? Each month, for over five years, these guys had carte blanche to dip into my checking account and withdraw whatever fees they deemed necessary to cover my premium. On the other side, the only thing I ever really needed from them was a prescription for Zithromax. So, let's do the math...

12 months of premiums at several hundreds of dollars each, equals about $6k/year.
$6k/year for about 5 years comes to around $30k.
Minus the $14.95 they covered for my antibiotics...

When you look at it from that angle, our friendship seemed to be extremely one-sided, to say the least. Which is why, when I injured my shoulder last summer playing softball, I thought it all the more perfect an opportunity for my friends at Humana to finally show how much they appreciated my support of them all these years, by stepping up to the plate and doing what I thought I was paying them to do for half a decade; get my back.

Sadly though, when the first in a series of $30k bills from my surgeon came in, almost as quickly as it began, our amazingly care-free, I'd-do-anything-for-you relationship ended. I was on my own.

Left hung out to dry so suddenly, I felt like Woody Harrelson in Kingpin, when Bill Murray pretends he's going to back him up, but, at the last moment, drives away. Leaving poor Woody to face the fury of a dozen angry rednecks, alone.

Here I was, now alone in spite of tens of thousands of dollars paid to ensure I'd never be. Left to face the fury of an onslaught of medical bills from the doctors, the hospitals, the anesthesiologists, and, of course, the physical therapists.

The way they get you, at least the way they got me, is they never tell you you're not covered when your surgeon's staff calls to check out your plan, pre-surgery. All they say is, "Everything looks in order," or "We concur surgery is medically necessary." No, "Stop the presses! You're not going to be covered for this under the plan you chose!" No, "You may want to pick a doctor that's in your network for this." None of that was ever uttered to me or my doctor's assistants. Thus, my surgery went ahead as scheduled.

Actually, the only hiccup pre-surgery, was when Humana screwed up my auto-pay and denied me coverage, thinking I had missed a payment. Once they realized their mistake, it was All Systems Go. Or, rather, "Everything's in place to pretend All systems are go, until we yank the rug out from under you."

See, I, like many others, did not read the fine print; which stated virtually no NYC-based doctor was in my network. Turns out, I'm not alone. According to Dr. Ron Noy of Prestige Orthopaedics, one of the top sports medicine clinics in Manhattan, "Many of the patients who come in to see me do not know what their actual benefit coverage is. They think their plan covers everything, but too often I have to sit with them and explain that, unfortunately, they actually have very little coverage. They're always quite shocked to find out that they, or their employers, have been paying higher premiums for coverage they are in fact not getting."

That's just the beginning. Upon being well enough to start physical therapy (PT), I was told my plan only covered 22 sessions. That may sound like a lot, but when you factor in the average rehabilitation time for a shoulder surgery of this type - which, compared to others, is considered minimally evasive - requires at least 36 sessions (an avg. of 3x/week for 12 wks.), you can see how my friends at Humana were prepared to let me live a long and prosperous life with an arm that would make the Tin Man look like a yoga instructor.

If it wasn't for the kindness of my amazing therapist, Karena Wu at Activecare Physical Therapy, who drastically reduced her rates once my plan ran out and I was left paying for each session entirely out-of-pocket, I would've had an arm that only went half-way up.

Actually, this is the one bright spot in this nightmare; everyone from the folks at ActiveCare to the staff at Prestige, to the administrators at Midtown Surgery Center went above and beyond to help settle my claims once they found out I was left hanging by my insurance company. I cannot thank them enough.

Throughout the course of numerous sessions, Karena and I would talk about the ridiculousness of the health care industry. The one thing that stood out and emphasized what a "Keystone Cop"-type of business model it really is, is when Karena stated that it's not uncommon for her to phone a provider trying to find out why they haven't been paid, only to be given an entirely different set of facts the second time around, ultimately informing her the patient isn't covered after all.

I completely believe in the 'bass-ackwards' type of double-speak these health insurance companies use, as a rep. from Humana actually had the nerve to tell me, for a bit more money, I could switch to another plan which would technically give me more therapy sessions, but that, ultimately, it would take about 6-8 weeks for that plan to kick in; at which point my arm would already be frozen with scar tissue. Another rep had the stones to tell me if I paid them x amount of dollars, they would cover the remaining sessions. Turns out, the amount of money they wanted came out to the exact amount it would cost me on my own.

Needless to say, after about three months of back and fourth with Humana, about the time I realized I was simultaneously paying 100% out-of-pocket for my therapy, while, at the same time, allowing them to deduct my monthly premiums from my bank account, I canceled my policy. In effect, I was paying them not to cover me.

Forget the mess that is currently Obamacare. Forget the stalemate that is our House of Representatives. If you want a solution to fix the nation's health care crisis, simply take away Congress's V.I.P. status and cast them down into the swamp with the rest of us. Do that, and I guarantee we'll have universal health care by next Tuesday.