When a health insurance company says that it covers annual exams, what do you think it means?
A) It covers one exam per year
B) It covers one exam per calendar year
C) Once you’ve had an exam, you need to wait 365 days before your next exam, or it will cost you $400
If you’re Aetna, you ignore common sense and go with choice C).
My wife got an annual physical last summer. Because our kids’ school system moved up the start of the school year this year, she got her physical about a month early, so that only 11 months had elapsed since her last exam.
When I saw the bill, I thought it must be a mistake.
The insurance company explained that their annual exam coverage meant that because she hadn’t waited 365 days, her exam wasn’t covered.
No big deal, I told her, just have your HR department contact them and explain the mistake.
Today, we received this response:
“Since Aetna has processed the medical claim appropriately & according to policy, an exception cannot be made on the claims processing.”
Now bear in mind, my wife doesn’t work for some tiny startup. Her employer is one of the world’s most powerful companies. It has nearly 160,000 employees worldwide. And yet Aetna still told my wife’s company to pound sand. They did the same thing to this guy.
This isn’t the end of the world. After all, it’s not like our experience is unique. “Aetna sucks” brings up 5,610 results on Google (versus 139 for “Aetna rocks,” a goodly number of which referred to the rocks of Mount Aetna in Greece). And an annual physical is pretty cheap in comparison to being denied heart surgery. Of course, Sean Semon’s sad tale took place in 2009. I’m sure they responded to the publicity, right? Oh wait, Sean is still waiting to get on the transplant list.
Look, a blog called “Adventures in Capitalism” isn’t going to proclaim the virtues of socialism or demonize corporations. They’re called “for-profits,” not “Red Cross.” But A) applying a policy in a way that seems completely counter to common sense and B) refusing to re-examine the issue even when asked by a Global 1000 corporation seems like pretty bad business.
I’d be happy to hear any alternate explanations that Aetna might have. Right now, it looks like it’s using the letter of its contracts to shirk the obligations that any reasonable businessperson would strive to meet.
This is why I like Kaiser; they don't get into silly nonsense about whether you did this or that – you pay your monthly fee, go to their hospitals, and do your thing. They were annoyingly bureaucratic in the past, but seem to have improved recently. Kaiser is more of a subscription model than an insurance model.
I briefly had Blue Shield, and they seemed to have a simple algorithm: they deny everything, you dispute their denial, and they'd usually pay it. It was annoying and frustrating as I had to yell at them every time I saw a doctor.
Kaiser has improved a great deal. Decades ago, they were a disaster area, but today, if you don't have special health needs, they're an excellent option.
Chris, aren't all the options (ABC) just the same? The policy is really, really clear. Being lenient just because you're a big corporation would really, really piss of people like me, who pay for their premiums themselves entirely. Your wife knows 1 year is 365 calendar days…she could have counted.
Anon,
The policy was never made clear to employees up front. They were simply told, "annual physicals are covered."
As for leniency, I wasn't arguing that big companies should get better treatment–I was simply showing that this wasn't a case of an insurance company discriminating against small business. In fact, this crazy policy applies to everyone.
A friend of mine who wants to remain anonymous provided this insightful take:
It's important to realize that your wife is not her insurer's customer — her employer is. Any behavior that minimizes expenses and doesn't impact client retention is rational for the insurer. If your wife didn't quit her job and her employer didn't change carriers, it's rational behavior. Especially given that your wife's employer has 160,000 employees to insurer, I'm guessing that price is their top criteria, not service. Is this perverse? Sure. But it's the direction that the market has driven the insurers in — keep costs down and compete on price. Since the buyer isn't the user, user experience can suffer. Hey, kind of like Microsoft in your other post!
Perverse is an understatement. Perhaps some things shouldn't be driven solely by profit. That path leads to the stagnation of human development; perhaps not apparent in the short term but definitely in the long run.