A medical catch-22

Lately my main financial occupation has been researching medical parity laws and investigating the likelihood of successfully challenging an insurance company's coverage caps.

I like my new job a lot, but as I've mentioned earlier, one area where it falls way short of my last job is on insurance. I'm now with Blue Cross/Blue Shield. I've always chosen PPO options for my insurance, even when it costs more, because I want the option of going out of network if I need to. I was prepared to choose the PPO option and pay more with Blue Cross -- until I realised that it not only carries a higher monthly premium than the EPO (that's fine), it pays less on in-network services. Unlike every other insurance plan I've had, Blue Cross doesn't cover all in-network medical costs (minus co-pays and deductibles). It pays 90 percent -- but if you're on the PPO plan (paying the higher monthly premiums), it only covers 80 percent of in-network services. The PPO plan also carries a higher deducible and an out-of-pocket maximum that's twice the EPO plan's maximum.

That is one hell of a stick Blue Cross is wielding to get you on the EPO plan.

Which I grudgingly elected. And now, of course, the doctor I want to see is out of network, meaning I'll be paying out of pocket for my visits. Even if I'd gone with the PPO plan, I probably still would be -- I don't think this routine stuff will exceed the PPO plan's deductible.

Meanwhile, David is separately insured through his company's plan, with Aetna. Overall, I suppose I can't gripe too much about Aetna. We've had annoying problems with bills being processed incorrectly, but that seems par for the course with medical paperwork. The overall coverage levels at Aetna are way better than mine through Blue Cross, and apparently better than industry average.

However. Like pretty much every insurer, Aetna caps outpatient visits for some conditions at 30 visits a year. After 30 visits, no more coverage -- it's like being completely uninsured.

This strikes me as a financially stupid approach, for both the insurer and the customer. Medical conditions requiring treatment don't magically disappear after a set number of treatment visits. If the condition gets worse, it could result in hospitalization -- and that's much, much more expensive for Aetna than continuing to pay for outpatient care would be. If a doctor is still saying the care is essential, then the insurance company should at least consider paying for it.

With insurer decisions to stop paying for treatment, you can appeal. It's a frustrating process with no guarantees, but the research I've done suggests that if you squeak loud enough and have the resources and persistence to jump through all the spiky hoops the insurers lay out, you stand a reasonable shot of getting what you're after.

But with these preset limits on coverage outpatient care, the insurers fall back on policy and flatly refuse to make exceptions. An appeal from the doctor handling our case was apparently rejected. A really well-done article in the Times Union newspaper last year found that no provider interviewed had ever heard of an insurance company making an exception.

I'm still going to file a written appeal with Aetna, even if it's fruitless, just to get a written response. I want papers I can hold in my hand while I continue yelping.

But what is really infuriating me about all this is the idea that we're paying $250 a month for medical coverage that is going to be utterly useless for the services we actually require for the rest of this year. Yes, if one of us breaks a leg, it'll come in handy again. Great. But for the care we actually need, we'll be paying out of pocket. Which would be much easier to afford if not for the whopping bill we pay each month for insurance.