Vindauga

A story in which I reveal why I am currently blaming all the problems of the world on health insurance companies

A while back I began to get a little worried about some of the moles on my arms. Finally, back in August I made an appointment to see a dermatologist about them. My health plan is through the university so I had to go to the health center and get a referral before I could visit the dermatologist, which I did. A couple of months later I actually got to see a dermatologist, it was in October.

The dermatologist intern guy was nice, even talked to me about the book I was reading (poor fella). And, big surprise, they were a little worried about a couple of the my moles as well. Oddly, not the same moles that I was worried about but, hey, they are the experts. The intern gets the actual dermatologist, who looks me over and agrees. And that’s when they decided to biopsy two moles (before you freak out, they are not malignant, I’m okay). So, I was sent home with two divots in my flesh, one on my arm and one on my belly.

I had to come back a month later, after the biopsy was done, just to make sure things were okay. I even got a certified letter stating this. I come back for my follow up and, thankfully, the moles weren’t malignant. They apparently weren’t normal moles though either; my moles fell in some middle range between “really horrible” and “totally fine.” I can live with that.

About a month later I get a letter from my insurance company saying ‘oh, by the way, you owe the doctor $500+ because we don’t cover this’ (that bill arrived shortly thereafter). I had been concerned about the possibility of having skin cancer, so when I signed up for this insurance program I made certain that they would cover exactly this kind of thing, so needless to say I was a bit surprised that they were denying me. But I had seen The Rainmaker, so I just figured their unspoken policy was to deny all initial claims. I called to find out what the deal was. They claimed that simple mole removal was cosmetic and therefore elective surgery, which was weird because I wouldn’t have opted to have chunks of my flesh disappear which at that point, months later, were still visibly indentations in my skin. And besides, would they really do a biopsy for a cosmetic removal? Fine though, it sounded like the doctors had just failed to explain properly and with the appropriate documentation all would be well.

So, I called the doctor’s office. Which, by the way, is on campus and part of the university’s medical school so, to say that they are familiar with the student insurance plan is an understatement. The woman that I spoke to in billing, when she heard my problem, said that they [the insurance company] does this all the time. She pulled my file and, sure enough, it said right in it that this mole removal/biopsy was because of an irregular mole. She assured me that she would resend this information and highlight the appropriate parts, and that this would get cleared up.

Then, at the end of December, I get another letter. This one is telling me that my follow visit isn’t covered either and that I am going to owe the doctor another $250 for that. I kind of just put this out of my mind, basically waiting for a second bill because I didn’t want to deal with this nonsense and also because I figured that the denial of the follow-up visit was dependant on the initial visit, which was, as yet, unresolved.

Then, today, I get a letter for my insurance company saying ‘thanks for appealing but because the mole was benign, and therefore not malignant, this was unnecessary and therefore cosmetic, we aren’t paying.’ You think I’m kidding;
“Thank you for your recent submission of an appeal for the above-mentioned charges. After a review of the information submitted and the insured’s policy it has been determined that the denial will be upheld. Nonmalignant warts, moles and lesions are not covered under the plan. No benefits are payable for these services.”
This is the point in the story where I started looking for bricks. Thankfully, I don’t know where there offices are and so no brick went flying through windows.

There are a number of things that I am just taking for granted.

1. the removal of a mole for cosmetic reason is a different process than the removal of a potentially malignant mole. I believe this because I still, 4 months later, have a divot in my arm and had this been simply to hide an unsightly mole it would have been a woeful failure. I assume that cosmetically removed moles don’t go for biopsy. I assume that potentially things like stitches or skin-grafts would be involved had this been purely for cosmetic reasons. The point of my assumptions is that, if I am right about any of them, then you don’t need to look at what the doctor said about the procedure, you need only look at what was being charged (tools, drugs, events, blah blah blah) to figure out the reason for the removal.

2. Affirming the consequent is a logical fallacy. It is, but my assumption is that everyone can see that it is obviously wrong to say “we know your mole was benign because we biopsied it therefore the biopsy was unnecessary.” Its one thing if you know its benign and biopsy it anyway, so I guess I am assuming that its clear that the reason for the biopsy was that we were unsure about the moles status as potentially life-threatening.

3. I assume that everyone at least knows someone who has seen The Rainmaker. We all know that some smarmy companies just deny all claims outright. We know this, and the insurance companies know this. Its a game, who is going to call who’s bluff? But would life just be easier for everyone if we moved on? I mean, this is the same sort of thinking that leads one to defect in the first round of a multi-iteration prisoner’s dilemma game. Grrrrr.

So, after being annoyed. I call the insurance company; I want to figure out what is missing this time so that when I call the doctor’s office I can tell them and this whole process can start again. After giving my information and explaining the situation to the woman on the phone she grabs my file and looks it through and tells me she sees enough of the right kind of wording and discussion in the original submission to warrant covering the expenses; “irregular mole is key.” She says that she is going to take this to management and they will get back to me, tomorrow morning at the latest.

I want to be clear about this. This has been denied TWICE. First, presumably out of hand but with at least a cursory look to its validity. Second, by an appeals committee/person. The woman on the phone thinks it should, clearly, be accepted. Which all leads me to wonder what the first two denials were all about. I am at loss whether to be really pissed off or content that this is probably done with. I am inclined to be content, I likely won’t have to deal with this anymore. But I ought to be pissed. This is an incredible waste of my time (we won’t talk about how much time writing this is taking); calling first one group and then the other, lying in bed being worried that I won’t be able to afford the bill, thinking (this afternoon) that next time I am worried about a mole I might be better off not getting it checked out.

And its the last one that really gets my ire up. The idea that preventative medicine is discouraged. The insurance company would be happier if everyone only had malignant moles removed then they would be if everyone had moles removed before they became malignant. I realize that there are some hypochondriacs and that there are some who take advantage of the situation. But it ought not be the case that one bad apple ruins the bunch and it ought not be the case that the squeaky wheel gets the grease. PAH!