What You Need to Know About Health Insurance Part 3

Note: This is Part 3 of an 8 part series that is also being published in the Chester County Press.

“Their Two Definitions for Covered Services”

As much as the insurance industry would like us to believe that the “Covered Services” for our healthcare plan are the services our insurer will approve and pay for, they are not. In fact, Covered Services are simply services that may be available, if our plan agrees to approve and pay for them in a particular instance. And, while this might seem a trivial point, I assure you it is not. It’s a misunderstanding that distorts the entire process of accessing the care we need and expect from our plan. Worse yet, it’s a misunderstanding that is actively promoted by the healthcare insurance industry, i.e., one set of Covered Services when we get our plan, another when it comes to paying for the care we need.

In an earlier article we stressed the importance of understanding that our health insurance is really nothing more than a membership in a “plan” that subcontracts the delivery of healthcare for a monthly fee.  Because, if we actually had health “insurance,” the Covered Services would be contractually defined in a signed and legally enforceable policy.  However, because our healthcare plan provides such no signed policy, there literally can’t be any contractually defined and guaranteed Covered Services. Consequently, what we are led to view as the care we are owed from our plan is nothing more than what the plan “might” approve and pay for.

Probably the best way to understand this deliberate misrepresentation of Covered Services is to ask yourself what your plan would say if asked whether a replacement knee is a Covered Service. I trust we can all agree the plan would reply with a resounding, “Yes.” However, should you actually need a replacement knee and your plan refuse to approve and pay for it, you will most certainly be told the plan is “Denying Coverage,” i.e., it’s not a Covered Service. It’s pretty much like having your house burn down and being told your fire insurance doesn’t cover fire damage.

Which leads to the question of how can a healthcare plan insist that a replacement knee is a Covered Service and then turn around and deny coverage for that very operation when it comes to paying for it. The truth is they couldn’t if your plan actually qualified as insurance. However, because what we are asked to view as health insurance is insurance in name only, our healthcare plan sees itself free to overrule our doctor and change the definition of Covered Services essentially at will.

The bottom line is that your healthcare “plan” wants you to believe the Covered Services so boldly displayed in glossy brochures and TV advertising will be there when you need them. However, they quietly reserve the right to decide when they are needed.

Fortunately, the success of this misrepresentation and billing scheme depends entirely on our ignorance of: 1.) What is actually owed from our plan and 2.) The laws and secret contractual provisions that shield us from the cost of the care we are owed. But, that’s a subject for another day.

See Other Articles in the Series