Insurance Math-When One Plus One Equals Zero
“Who reads insurance policies?” my pastor said rhetorically to a very distraught parishioner as we visited in his office. I didn’t think much about the statement until later, my wife’s illness the far more painfully urgent focus of our discussion, but as I think back now over my 64 years on the planet I can only remember one time I carefully read any insurance policy. When I did I was standing in two feet of water inside of our opulent mobile home in the aftermath of Hurricane Juan in Louisiana, and discovered we weren’t covered for floods.
Our recent situation is similar, but emotionally, 100 times more traumatic and way more expensive. Message? Break out those policies brothers and sisters and make darn sure you know what you have and what you don’t. Secondly, don’t feel stupid if you fail to understand what’s in print both large and fine. I have three college degrees, one of them in communications, and I often couldn’t interpret the specialized language commonly reading like some ancient incantation. I believe this is most deliberate, common coherency in insurance documents one of many changes greatly needed to even begin to modestly repair the awful mess impersonating an integrated health care system today.
Insurance policies, like most legally binding contracts, are written, or at least carefully reviewed by, lawyers for other lawyers, and even then, often require legal expertise in medical areas many lawyers don’t have. The good news is a savvy insurance agent in a competing company often can and will interpret a competitor’s policy for free in hopes of attracting business, and also, many times, just because he or she wants to help. Many large employers also have people on staff trained to interpret insurance documents. There are also many agencies offering free or very low cost assistance in understanding and navigating through Byzantine insurance language used for both public insurance like Medicare and private policies, and most commonly, a mix between the two.
No matter what route you choose, it is essential to know what your insurance will and will not do long before you need it. Not remotely understanding my wife’s so-called medical insurance was our first and most serious mistake, one we could have easily and inexpensively avoided entirely, but didn’t because we thought, incorrectly it turns out, someone else was looking out for our best interests.
Both my wife and I sailed blindly under an illusion of protection for over two years. We regarded TRS as benign and on our side, and actually had very good reasons to think this way largely due to the way TRS presents itself to the public, as does just about any insurance company. From “You’re in good hands with Allstate” to “Aetna I’m glad I met ya,” insurance PR departments churn out all sorts of reassuring messages, but the tune often changes dramatically when big bills arrive. In the case of TRS, the following malarkey, taken directly off the agency’s web page, is largely how we viewed our “protector.”
“It’s the reward you’ve been working toward. You shared your talents over many years or even a whole career in service to Texas public schools, universities, or health care institutions.
So many Texans trusted that you would be there for them. You can trust that TRS will be there for you every day, every step of the way. Offering lifetime TRS-Care health benefits for you. Paying monthly retirement payments for life. Providing a friendly voice on the phone or a warm personal greeting as you navigate these years.”
Not only wasn’t TRS with us “every day, every step of the way,” it didn’t even bother to respond to a desperate cry for help this past November when the walls fell in and it sure wasn’t with us when my wife first transitioned into retirement. Make no mistake about this, when it comes to all insurance, especially health insurance, we are all only tiny bits of data swimming among millions if not trillions of other pieces of digital information only robotically reviewed by computers today in most cases. Should an error occur as it did with us, both on our part and on the part of TRS, no one will be around to sound an alarm and that helping hand shown along with the paragraphs I just quoted from a TRS web page can very quickly mutate into a slap in the face. Bottom line? Protect yourself. Trust no one completely. Verify everything.
We fell into the insurance tiger pit for a number of reasons, the first I just reviewed, not carefully reviewing our insurance, thinking we weren’t in some dangerous adversarial relationship like buying a used car and instead really part of a large Texas family that would look out for us in times of need. We felt no urgency for careful scrutiny as we would normally take in nearly all other business transactions where “caveat emptor,” Latin for “Let the buyer beware” is the most common legal standard applied. Not being the least bit cautious was a huge mistake.
Speaking of huge mistakes, we were greatly aided and abetted in our insurance felony by TRS itself also making an assumption based on error. Had this not happened, according to a TRS rep I spoke to over the phone, an alarm would have been sounded in our case, one dealing with perhaps the biggest health insurer of them all, the federal government. How the feds were mixed up with a Texas insurance program is, to me anyway, most ironic, former Governor Rick Perry once indicating Texas should secede from the union as it had in the past. I don’t need to tell any remotely aware Texan about the often-adversarial posture Texas presents to Washington on all sorts of issues, an insurance partnership seeming unnatural, like Donald Trump hiring Kim Jong Un to design a US missile defense system. However, when it comes to saving a buck, Texas wasn’t a bit adverse in taking what it didn’t want to give, in this particular case full health insurance for a 70-year-old state retiree.
Mary’s second great sin was to work for SAISD that happens to be one of the few districts in the state participating in Social Security and consequently making my wife eligible for Medicare Part A at no cost and Medicare Part B, which I now painfully know is real health insurance available for only a modest premium, one we would have gladly paid for had we only understood not doing so was roughly equivalent to jumping off a cliff into a pool of piranhas.
For a long while in the midst of this disaster, I had no clear idea how we failed to understand the critical importance of Medicare Part B, and must admit only recently learning the entire Medicare A-D alphabet, something I’d urge anyone over 60 to commit to memory ASAP.
After the initial shock wore off and I began to think we weren’t destined to live in a tent under I-10, I started digging through paperwork I have no previous memory of but my wife was at least wise enough to stuff in a bottom drawer and most likely at least read. In this mass of paperwork I found a letter dated 5/1/15, the date only significant to us as it coincided almost identically to the date we placed my mother into a local nursing home after enduring over six months of arduous care for a totally incapacitated dementia patient most prone to yelling at all hours of the day and night about monsters that didn’t exist. These conditions kept both of us so seriously sleep deprived we pretty much operated on autopilot for months, two zombies just trying to survive day-to-day as best we could. We couldn’t have picked a worse time to make a critical transition in life, but actually, my mom’s care was a big part of the original transition plan, my wife realizing she needed to retire to help take care of mom before both of us dropped dead from exhaustion. I can’t honesty say I ever read the letter when it arrived and know for sure I had no recollection of it until finding it recently.
In the letter, however, was both the error TRS made, having Mary covered under Medicare Part B, and also a paragraph in the body about Part B which reads:
“Under TRS care claims will be paid as if Medicare Part B medical insurance has been purchased. Therefore it is beneficial that you and your spouse, if covered, purchase Part B of Medicare when you reach 65.”
Due to both exceptional circumstances in our life and a supremely understated caution, we missed the warning entirely as well as the error in the letter. I’ve since explained to TRS that its failure to communicate was partially due to what communication professionals call “noise” which means any circumstance that hinders accurate and effective communication. I also emphasized all competent communication pros realize and plan for a very high “threshold of awareness,” another communication term, meaning the average person frequently needs repeated and most vigorous prompts in order for a full or even partial reception of important messages. I then suggested what should have been in the letter in large bold type instead of the muted warning:
“All Medicare eligible TRS beneficiaries who turn 65 MUST purchase Medicare Part B to insure adequate medical coverage. A failure to purchase Medicare Part B will result in denial of benefits for doctors’ fees and other necessary medical treatments that can result in enormous medical bills for the retiree that are not covered by TRS.”
Even in the state we were in at the time, had my rewrite or something similar been used I have little doubt a most important message would have been effectively communicated. What I didn’t understand at first was why this didn’t happen in the first place, knowing that TRS, because on my retirement processing, was staffed with a lot of helpful, intelligent people who sure appeared sufficiently educated to understand lessons I taught to high school students.
And that’s when political reality and the posturing we see today on both sides of just about any controversial issue became most apparent. What Texas did and is still doing is transferring the bulk of its responsibility for TRS retirees’ health care to the federal government when it is possible to do so. However, Texas didn’t want to blatantly advertise this clever responsibility shift in plain language, so instead it used words like “beneficial” and stepped ever so lightly around the issue. In this way it made it seem TRS provided far more benefits than it actually did, and in so doing completely fooled us too, and then compounded this deception by apparently deceiving every medical establishment we encountered, to me the most damning crime of them all.
What enraged me the most initially and still does is that we were left essentially naked in insurance land for over two years when there was plenty of time to correct a simple error long before huge cancer bills accumulated, had someone taken the time to do so. Instead, my wife was provided with what I’ve since called “counterfeit documents” because for some very stupid reason TRS decided to name a completely different insurance package using an identical name “TRS Care 2” that I also carried in my wallet and used when needed that was actually real medical insurance. Most importantly, the many times my wife saw her primary care provider, she only made a modest copay and received treatment, just like I did. All seemed perfectly well for over two years while storm clouds quietly gathered overhead to form Hurricane Cancer.
How and why the illusion lasted for as long as it did is partially related to modern insurance and medical billing practices, another facet of our badly flawed gem we’ll review soon
Next Up: Part 3- Doing the Medicine Dance