Thursday, September 11, 2008

What does YOUR health insurance cover?

My health insurance, for which I pay $395 per month, will not cover the foot surgery my doctor says I need: a toe joint replacement that is supposed to last 20 years and which will restore mobility and reduce pain.

Aetna won't cover this; according to them the procedure is experimental, though it has been FDA approved. Aetna will, however, apparently approve two other procedures: fusing my toe to my foot so it would never bend again, or removing the joint so the toe sort of flops around. Yuck. But both options are supposed to eliminate pain.

I'm going for the surgery. Just how much does foot surgery cost, per foot? Despite numerous phone calls, calculating the exact total remains an unsolved challenge, because so many entities and individuals are involved: the Dr, the surgery center (which at least offers a 20% discount for patients paying out of pocket), the anesthesiologist, physical therapy (no clue yet what that'll cost). Then there is the boot I'll need to wear, plus pain medications and??? I don't know what I'm missing.

Can you imagine a cost conscious consumer going into a department store and buying a dress without knowing precisely how much she'll pay? How can you dispute a charge after the fact, if you've been given and then used a product or service?

Can any government fix problems like this and make it easier for patients to be informed?

Anyone who is happy with his or her insurance provider, feels comfortable with finding out accurate information, understands those Explanations of Benefits and has needed procedures need covered effiiciently, let me know!


Gina Black said...

I'm assuming that you have moved up channels on this and aren't just taking no for an answer? If it's FDA approved how can it be experimental? Grrr. I'm angry for you.

I have great insurance but it's from the DGA for members only.

Anonymous said...

Wish I could help, but I can't resist responding to your question about "can any government help": single payer national health care would eliminate all this nonsense.

See, for instance, Physicians for a National Health Program at

Best of luck! I'm blogging about your case at Correntewire,

Ruth said...

Thanks Gina,

There's a clinical policy bulletin against the procedure I need:

And I can't really wait to see if their upcoming review changes the coverage.

Ruth said...

Dear Anonymous:

Thanks for posting...I will check out your blog!

Anonymous said...

Ruth, I read about your situation over at, and hate that this is happening to you.

I want to second that you must take this up channels. Then, if they still deny, go to your local consumer problems reporter. Try your local congressional rep. State officials. State insurance commission.

Here in the NYC metro area, the bad PR a consumer reporter creates tends to cause the insurance company reps to revisit their initial decision. It may take time--and I don't know how badly that will affect your probable outcome. But give it a try.

I was incredibley impressed by a young woman at the head and neck cancer group I attended for awhile who had tongue cancer and had trouble speaking. She wanted treatment which would quite possibly save her tongue (which makes communication much easier), but initially her insurance company wanted to just have it amputated. She managed to work through the system and get the treatment she needed at the hospital which could provide it--and now speaks normally. Yeah for her!

Not easy--and she was an amazingly persuasive person, but do whatever you can to maintain mobility.

Best wishes to you,

Ruth said...

Thanks, jawbone, for your good wishes...I am pondering a couple of options.

splashy said...

It just amazes me that so many people want to have our health care system as a "free market" and yet it's pretty much impossible to actually find out how much something will cost. How on earth is a person supposed to make an "informed decision" about it if you can't find out how much you will be charged?

Do we get to bargain it down? What is up with all that?

Hope you are able to work it out to your satisfaction!

Eileen said...

Argh stories like this break my heart. I adore Canada's health care system. Adore it. Couldn't pay me to go back.

Anonymous said...

I came across this blog because I too have a similar problem with my insurance company Harvard Pilgrim which has the same "not covered" experimental policy. After having paid into insurance for over 30 years this is the first major procedure I really need and they say its not covered. I am not going to let them get away with this. I will check back to see how you are doing. Good luck.