Insurance refused to cover patient's $75 medication — then ended up coughing up a $4500 monthly payout
'Corporate stupidity at its finest... No wonder medical care in America costs so much!' they said.
The healthcare system is flawed, and insurance has been the support net for many. However, when that support disappears, patients are often left scrambling to figure out what comes next.
A patient who goes by u/LeathalBeauty shared a post on March 16 about how their insurer suddenly refused to cover their annual medication plan. The plan, which initially cost under $75 a month without insurance, was abruptly denied before they would begin the new year's plan. They got in touch with the company’s patient advocates and finally found a solution in their favor, except that it cost the insurance company $4,500 per month.
The patient mentioned that they have frequent issues due to which they need constant medication, including IVs. The patient can only take the liquid form of medication due to certain restrictions and prerequisites. “I had been taking medication for my thyroid that worked well and was covered by my insurance,” they explained. However, just before they could start the new year’s plan, they learned that the insurance was denying the payment of their medication.
“The medication cost without insurance is less than $75/month (under $1,000/year),” the author noted. They immediately got in touch with the advocates.
After nearly two weeks of back and forth with the company and the advocate, a solution surfaced. “The patient advocate asked the pharmacy department of the insurance company to list all options that are covered by my plan,” the post read. It was then learned that the insurance had to cover the medication “no questions asked.”
Since the cost-effective option was denied, the company had to pay up per the other provisions. So instead of paying a few hundred dollars at max, “the IV medication cost to insurance is $4,500 per month.”
“So here we are, my $900/year medication that is now excluded from coverage is now costing the insurance company $54,000/year!” The patient was glad there was no loss at their end, but it also pushed them to wonder how many people struggle because of the system.
“Corporate stupidity at its finest... No wonder medical care in America costs so much!" they said, and their statement holds true. While insurance is meant to assist people, greedy and profit-oriented companies are making the struggle worse. According to polling data from KFF, 36% of Americans said they postponed or denied healthcare in the past months due to the cost. 41% of adults reported having debt due to medical bills.
38% of people under the age of 65 were worried about being able to afford health insurance. Data from The Commonwealth Fund from a survey on 7,873 adults above the age of 19 and under the age of 65 revealed the upsetting reality. 45% of the sample reported receiving a medical bill to co-pay that they thought was being covered by insurance. 17% noted that their insurers denied coverage of medication prescribed by their doctor. Six in 10 adults said their treatment was delayed due to the coverage denial.
Fortunately, this patient was able to teach the insurance company a lesson. In an update, they revealed that after getting a solid comeback for their action, a few days later, they “reached out offering to cover my original medication and inquired about how soon my doctor could change my prescription.” However, the patient is keen on letting them learn their lesson for a bit. “I'm thinking now might be a good time to have other denials revisited before my doctor changes the prescription."
u/Think-notlikedasheep said, "They did the math. They got the wrong answer lol." u/raz1161 added, "This prompted me to compare my pharmacy charges against my insurance. I will go talk to my pharmacist. I am being charged more than I should if I am reading this correctly."
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