Health Care Requires More than Insurance

Late last year while playing tennis I reached up to serve and I felt a painful pop in my shoulder. The inflammation got worse over the next few months. Now anytime I try to put my arm above my head, pain shoots up my arm. I often wake up at night with an agonizing throb in my shoulder.

So I finally and reluctantly went to the orthopedic surgeon and he said that I had a rotator cuff tear and I probably would need surgery. Ugh. He scheduled me for an MRI but the day I was set to go, the hospital called to tell me my insurance company declined to pay for the scans. The insurance company, CIGNA, tersely sent me a note: “You will need to complete six weeks of conservative treatment, such as physical therapy and anti-inflammatory medication. Once that has been completed and you have been re-evaluated, we can try to have the MRI re-authorized.” Gee, thanks. You guys are the best.

What’s that about? I’ve been doing therapy for many months already with not much improvement. The doctor explained that the insurance companies want to make sure that physicians aren’t padding bills with unnecessary procedures. Incidentally, I’ve paid for health insurance for 30 years and have almost never used the medical care system. I calculate the insurers have made well over $100,000 off of me.

But I am lost inside the bureaucratic maze. They don’t want to pay for the MRI because they don’t want to have to reimburse for rotator cuff surgery. So their hope is that I will just go away. Studies show these delay tactics and bureaucratic runarounds work to reduce insurance payouts.

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