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I highly recommend the NPR series, “Bill of the Month,” which offers an expert analysis of medical bill surprises.

This month’s bill concerns jaw surgery and a hospital bill of more than $27,000. The patient, Ely Bair, had a condition requiring two jaw surgeries. The first jaw surgery went very well and Bair paid his out-of pocket maximum of $3,000 and his employer’s health plan with Premera Blue Cross covered the rest.

Bair’s second jaw surgery was with the same hospital and the health insurer was also Premera. But this time, Bair received a bill of $27,119 from the hospital.

The reason is in the fine print.

Although Bair was covered under Premera policies for both surgeries, he changed employers between the two surgeries. Although both employers used Premera, the insurance coverage provided by Premera was different for each employer. The second Premera plan had a lifetime maximum of $5,000 for this jaw surgery. That left Bair responsible for the rest of the hospital bill. When he appealed, Premera pointed him to the specific language in the 80-page policy that addresses the lifetime maximum for this specific surgery.

There are two lessons here:

  • First, read your health insurance policy before undergoing any significant medical procedures. Health insurance policies are lengthy, not easy to read, and contain insurance terminology (i.e. out-of-pocket maximum) that is not readily understandable and requires explanation. If you have questions, ask the insurance company, ask your employer’s human resources department, or ask your state’s Department of Insurance for help.
  • Second, advocate for yourself. After receiving the hospital bill, Bair filed a complaint with the Washington state attorney general’s office and the hospital reduced the bill to $7,164. Bair’s advocacy resulted in a savings of almost $20,000.

If you’ve found yourself or a loved one confounded by your health insurance policy language and feel like an attorney may be able to help, please contact Kantor & Kantor for a free consultation with one of our Insurance Lawyers or use our online contact form.