Wes, Greene County

Wes and Linda purchased a health insurance plan. They did not qualify for subsidies under the Affordable Care Act (ACA) and their premiums rose significantly. With premiums rising to over $2,000 a month with very high deductibles, they decided to search for other options. In 2019, they decided on a short-term health insurance policy, which was not ACA compliant, to protect themselves in the event of a major illness. The short-term policy they chose had a monthly premium of $1,100, a $1,000 deductible and a total maximum benefit of $1,000,000. Their medications were affordable so they did not include prescription coverage to keep the premium down. Wes and Linda understood the plan did not cover preexisting conditions, but rationalized they were both healthy and did not need this coverage. They could afford smaller medical expenses, they only needed protection for major medical expenses.

In January 2019, just two weeks after the new health insurance policy went into effect, Linda experienced severe abdominal pains so Wes drove her to the hospital emergency room. A doctor determined her gallbladder needed to be removed. Outpatient surgery was scheduled that afternoon and Linda was home by evening. Three days after surgery, Linda fainted and her blood pressure dropped extremely low. Unable to sit up without feeling faint, Wes called an ambulance to transport her to the hospital. The doctor determined she had blood clots in both lungs. Linda was admitted to the Intensive Care Unit for three days until the clots were dissolved.

In March, Wes and Linda received a letter from the hospital asking for assistance in getting the insurance company to respond to the claim filed for the outpatient hospital stay. Wes contacted the insurance company and was told they had never received such a claim. Checking back with the hospital, he learned the claim had been sent in January, again in February, and by certified mail in March. The hospital sent the claim again in April. Meanwhile, Linda learned that the insurance company wanted medical records to review for a possible preexisting condition related to her hospital stays. As Wes states, “They received records going back 15 years and it still wasn’t enough. They asked for a list of all the doctors and hospitals Linda had seen or been to in the past with contact information. I told them it should be in the records that were sent, but I would compile the list and send it certified mail”. Despite all of his efforts, the hospital received a letter from the insurance company in June stating the medical records were insufficient. Wes contacted the insurance company and was told they needed to know the exact date Linda was diagnosed with the pulmonary embolism, even though this information was clearly indicated as the date Linda was admitted to the hospital.

The preexisting condition issue was settled in August – there was no preexisting condition. The After all of this, they still received bills ranging from $917 to $22,383. Wes sought help by calling the Missouri Department of Insurance Consumer Protection Hotline and filed a formal complaint mid-August. He credits this agency for helping to move the insurance company to action. Wes’s advice, “document, document, document! I have no idea how many hours or days I spent on the phone, 100 hours at least. I kept a record of every phone call made, the date, who I talked to and what was said”. In the end, they were left with a $917 bill. A steep price to pay for someone with insurance but much better than the over $20,000 bill.