On paper it may seem to insure you against catastrophic loss, that is, if the insurance company can't find a way to deny your claim for one reason or another. You can surely bet they will be trying.
The first year, we could actually purchase decent coverage and while it was expensive, it was a solid PPO plan. The past two years however, there isn't even a single PPO plan offered on the exchange in my state -- not one -- I don't even think there were any "Platinum" coverages offered. The end result is that we pay essentially a mortgage-size payment each month and in exchange we get relatively abysmal coverage.
Worse yet? It seems they categorically deny ~75% of claims, which generally means we have to appeal & fight them on it (our success rate is high but it's time-consuming); if it's testing/labs that need done, we also have to front the cash out of pocket to avoid delaying diagnosis & any potentially needed treatment. Often that means $800+ out of pocket PLUS a 4-8 hour time investment over a 3-4 month span in order to try to recoup that money -- all the while, we're of course paying the absurd premiums each month.
Insurance & the financial aspect of healthcare is so completely broken in the US that it's sickening. I believe the problem is so severe that it's really hurting our country's economy and is incredibly stifling for individuals & small businesses. I wish I knew how to fix it. :(
My business was going well. I was making equivalent income of a bit more than a high-end salary for my skill set in my area. I was fine (grudgingly) paying the premiums.
The problem was that there was absolutely no assurance insurance that would actually cover anything would be available in the future. We had "marketplace" plans for a number of years. Eventually there were no "silver" marketplace plans available in my locale (and "bronze", with 20% "co-insurance", means I'm going bankrupt if I have any significant events anyway, so I might as well just have no coverage).
I gave up and took a job. I couldn't expose my family to the risk of not having any insurance available. It was crushing.
I took the route of not having employees and was unable to qualify for "business" plans. I guess I wasn't "successful" after all, since I didn't aspire to grow the business beyond what would support my family.
When we had a kid, it was $10K out-of-pocket, and we had a bunch of "out-of-networking" bingo due to mostly lab tests or a doctor out of network at an in-network ER.
Since then kid themselves also had an ambulance ride (seizure), and that too was "out of networking" in spite of being the only ambulance provider available within 15+ minutes.
A quick google suggests this is common:
> It's important to understand, however, that the out-of-network emergency room does not have a contract with your insurer, and is not obligated to accept their payment as payment in full. If the insurer pays less than the out-of-network emergency room bills, the emergency room can send you a balance bill for the difference, over and above the deductible and coinsurance amounts you pay.
>Since then kid themselves also had an ambulance ride (seizure), and that too was "out of networking" in spite of being the only ambulance provider available within 15+ minutes.
That's the illegal part.
The $1,500+ ambulance bill still existed, I still paid it, and my kid wasn't even born until five+ years after the ACA came into force. The insurance company was "nice" enough to let me count it towards my kid's deductible for that year, but I paid every cent.
Stop using "victim blaming" as a way to shut down discourse.
In every country in the world people run scams. Universal healthcare would make these particular kinds of scams a lot harder, but I guarantee you, you could still find this kind of anecdotal evidence of criminal behavior relating to healthcare.
It's possible for the out of network provider to then bill separately from your insurance if they charge more than what your insurance pays out of network providers, but there's no way that's what happened here because $1500 after the out of network fee from the insurance company is far too high for an ambulance trip.
It was all out of pocket. At the time, insurance would not cover midwives, nevertheless a home birth.
For our first birth, a hospital would have been a terrible, terrible option. By the time of our 4th birth (10y later, twins), hospital birthing environments had vastly improved. Our OB/GYNs practice was 100% women w/ midwives on staff. The only thing we missed was having a doula.
The most common method of denying claims was that it was a preexisting condition, something that ACA prevents them from doing. The vast majority of people who have health insurance will be covered in event of a catastrophic illness. It's definitely more than just "on paper".
If people think multi billion dollar insurance companies are trying to nickel and dime them for medically supported treatments, then I don’t know what to tell them other than it’s simply not in their interest to risk so much for so little.
The most common denial reason is for doctors ordering brand name drugs that cost 10x more than a generic, but have no data to show they are any better. Or drugs that aren’t shown to have any effect, but doctors just want to appease the patient or experiment.
My diabetic friend has documented bad reactions to the expensive name brand insulin and a couple of others, but not a specific cheap (relatively speaking) one.
His insurance mandates that he use the name brand exclusively and will categorically deny any other form of insulin.
Now, maybe this doctor is just prescribing insulin to a fucking diabetic to appease the patient, but for some reason I doubt that's the case.
Any denial, is prima facie, going to save money versus paying any claim.