For whatever reason, I am a frequent flier at my friendly neighborhood cardiologists’ office. (No, I had this problem before Covid was A Thing)
So, once I noticed that I was having to work harder than I thought was proper, after exertion that I thought was sort of trivial (as in, ascending the stairs with a basket of laundry), I arranged to chat with cardiology.
I saw one of the midlevels in the office, and recounted my present experience, and set that in the context of my previous (atypical presentation) experience with my angina/narrowed cardiac arteries.
That worthy basically said, “Hmm. So, this present experience sort of mirrors your experience with previous cardiac caths, which were associated with significant arterial stenosis. I betcha you would benefit from another cath, which might result in yet another stent to add to your collection!”
And, so was it done.
For those not steeped in The Mysteries Of Cardiac Caths, a long narrow tube (a catheter) is threaded into the left atrium (upper chamber of the heart), and from there into the cardiac arteries (which originate from the left atrium). Once there, x ray contrast dye is injected, and images captured, establishing the free flowing nature of your arteries (or, so one would hope!), or, alternately, the fact of constriction and the degree of that constriction.
Should a sufficient degree of constriction exist, the catheter is threaded into that narrowed portion, and a balloon is inflated (with sterile saline), opening up that part of the artery.
When it works, and the artery remains open, Yahtze! (er, I mean, Score!). The cardiologist moves along to whatever other matter appears to be part of today’s investigation.
If it does not remain open, the doctor will place a stent to keep it open.
By the way, that dye is hard on one’s kidneys. If one is a geezer, as I am, and has marginally performing kidneys, as I do, the doctor has to limit the exposure your kidneys have to this dye. This fact meant that during my Fun! Time! In the Cath lab in August, only the higher problem constrictions were addressed, so as to limit the amount of metaphorical pain my kidneys would experience.
Since there was another artery significantly narrowed, it was medically reasonable and prudent that I have a rematch, once my kidneys had quit (again metaphorically) glowing.
I had that cath, did not require another stent, and we all lived happily ever after.
But, WAIT!
I subsequently, like 6 weeks subsequently, received a letter from my insurance company that asserted that my second stent was NOT “medically necessary”. (as an aside, I am unable to imagine who the frack would have a cardiac cath for giggles. I mean, rilly?!?)
I called the “customer service” number, and the soul who answered me led me to conclude that their call center is located (a) in Bagwanistan, and staffed by (b) retards.
The first chucklehead with whom I spoke, could not grasp the concept that “You assholes told me that my cath was not medically necessary, an opinion not shared by my, oh, gosh, CARDIOLOGIST, who, himself, kind of WENT TO SCHOOL FOR THIS VERY SORT OF DECISION MAKING!
After 10 or 15 minutes of trying to communicate this to Young Bagwanistanian Einstein, I asked to speak to a supervisor. Repeatedly.
Conveniently enough, Einstein’s supervisor was not available, a fact shared with me after several minutes on ignore. Einstein offered to transfer me to “authorizations”, and I requested that he do so.
The next genius made Einstein appear to be a Mensa member. We go to the point of her revealing that her records asserted that I had $2.96 yet to pay on my “individual out of pocket maximum”, and therefore would owe $1789 or some such as my copay for the second, contested, cath.
Ms. Mensa related that we had a family out of pocket maximum of $7,000, and that I had pain $3497 toward deductible and co pays, and The Darling Wife-Mark II had paid $3,500 toward hers.
I asked how it worked that I owed $1789, when my out of pocket maximum was $2.96 short of the contractual amount.
“Well, that is an aggregate amount. Until you have paid your deductible, and your co insurance (read: “co pay”), and the both of you have paid $7,000, you still have to pay your co pay”
I asked Ms. Mensa what the phrase “individual out of pocket maximum” meant? Since My understanding was that I would pay my deductible until my deductible amount had been paid, and thereafter I would pay 20% of the bill, until I had paid my individual out of pocket maximum, which was $3500. At that point, per my explanation of coverage that I received when I signed up for this insurance, I would not pay anything for covered services.
Oh, no, Ms. Mensa corrected me. “Out of pocket maximum” was aggregate, and we would have to pay $7,000, before the “no more out of pocket costs” coverage would begin.
I asked her to tell me what the phrase “Individual out of pocket maximum” meant? And, if there was no non aggregate out of pocket maximum coverage, why would your attorneys include such confusing language?
“Let me place you on a brief hold”.
SEVERAL minutes later, she came back on the line. “That out of pocket maximum is an aggregate. You have to have paid $7,000 for the two of you before your out of pocket maximun applies”.
So, The Darling Wife Mark II got to see That Face When You get to school the insurance lady, on a not particularly obtuse item of insurance coverage, which even the cardiologists’ office as well as the hospital at which my cath took place, are able to understand.
Like the difference between “individual” and “family”, and the different out-of-pocket maximums that contractually apply.