The question journalists need to ask when covering health insurance

Like many people, I’ve been following the stories of people who are losing their health insurance as insurance companies cancel policies because they don’t meet the standards of the new health care law. People insisted they “liked” their old policies.

And maybe they did. But it’s time to demand we get a look at those policies. Several journalists have followed up with policyholders who complained on national TV that they were losing the policies they liked and found out that in most cases, the policies were garbage. What they liked, in many cases, was the idea of paying a relatively small amount of money for garbage.

When’s the last time you sat down and actually read your insurance policy?

If you’re one of them, explain in-network vs. out of network? Explain co-pays to me. Explain out-of pocket maximums to me? Explain amounts allowed vs. provider responsibility. The best way to get educated on your insurance — and whether it’s worth the money you spend on it — is to try to use it.

I like to think I’ve got pretty decent health insurance, but even the people who sell it don’t know what it is. What hope is there for the likes of me?

Here’s an example: In my continuing struggle this year with the illness I described earlier, it was suggested I buy this Medtronic device, which retails for $3,500 and appears to have about $12 worth of parts.

I consulted this page on my insurer’s website and learned it’s “Generally covered subject to the indications listed below and per your member contract.” Well, good then.

Not having the member contract handy, I called the company and asked the representative about it. “You’re fully covered,” she noted, advising me also that I’d already met my “in network” deductible of $3,000, whatever that meant. But fully covered in the insurance world does not mean “covered in full.” It means the insurance company will pay for the portion of the cost of health care that they’re bound to pay for. And we all know without looking what that is, right?

So I bought the device, stuck it on the credit card and then submitted the claim to get reimbursed.

That’s when I found out that Medtronic is considered by my insurance policy to be an “out of network” provider. It also didn’t matter whether my “individual deductible” ($750 for in network and $1,500 for “out of network”) might have been met because there’s also the “individual out of pocket” ($3,000 and $4,000 respectively) to consider. There’s also the “family deductible” and “family out of pocket” to consider. (By the way, if you’ve met your out-of-pocket maximum for the year, many providers will still collect the co-pay for an office visit and the chances are pretty good you’ll never get reimbursed for it.)

When the dreaded EOB (explanation of benefits; a woefully inadequate term) arrived, it carried a check for about $1,600, which is better than nothing, but comes a bit short of the “fully covered” I had been led to believe.

They weren’t lying at my insurance company. They paid exactly what they were required to pay and it was all right there in the EOB which lists charges, the provider responsibility amount, the allowed amount, the co-pay amount, the deductible amount, the co-insurance amount, the patient non-covered amount and finally the grand total “the paid amount.” Armed with those numbers, a calculator, and maybe an hour of time and a good friend in the health insurance business, I could figure out how they reached that amount for the medical device, which, by the way, doesn’t seem to work that well.

I consider myself lucky to have the insurance I have and to have gotten what little I got for this one claim. But, though I consider myself a fairly intelligent sort I don’t pretend to fully understand the byzantine nature of the coverage and I don’t pretend to understand how anyone would be able to know how covered they are in this system that often seems to depend on the customer not knowing what they’re paying for.

You can’t get to the point where you like your health insurance if you don’t understand your health insurance.

It’s worth asking people who are upset that their policies are being canceled what the policies cover? In many cases, I suspect, the proper follow-up question would be obvious: Why are you happy with it?

Related: David Brauer goes shopping for health insurance.

Another Obamacare horror story debunked (Los Angeles Times).