Werewolves of Wellpoint

    But I was almost ridiculously low-risk and healthy before getting sick in 2002, so there was really nothing they could do. I remember coming across a news story that  my particular habits (never being overweight or smoking, regular vigorous exercise, healthy diet and so on) are shared by a mere 3% of Americans.

    Governor Arnold Schwarzenegger unveiled his plan for expanded California health coverage this week, even as the Los Angeles Times reported that three major  insurance companies in this state РBlue Shield, PacifiCare and HealthNet Рhave been excluding entire categories of workers (roofers, volunteer firefighters, migrant farm-workers, among others) as too risky. In addition, these three companies, along with Blue Cross, often refuse to cover people who take preventive prescriptions for common maladies such as asthma or heartburn.     

¬†¬†¬† None of this applies to anyone with group coverage through their employers; only to those who, like me, have individual coverage. (These are also the policies that Blue Cross retroactively voided.) And that’s the problem. The California economy runs on free market enterprise – from actors to accountants – but it’s hard to see how this is sustainable unless we get rid of the ridiculous notion that health insurance must be linked to employment.

¬†¬† Even though I have by most definitions good coverage — about $400 per month covers me and my daughter, with a $2,500 deductible for each of us –¬† I’m afraid that I still have to count myself among the underinsured, if only because there’s nothing to stop my out-of-pocket cap from being raised to whatever Blue Cross feels like raising it this spring.

¬†¬†¬† They can’t single out sick subscribers by raising only their premiums or deductibles. But they can raise the out-of-pocket cap, because (as a customer service rep explained to me over the phone) that’s considered “a benefit.” And of course, only sick subscribers even know what an out-of-pocket cap is.

    I typically reach my $2,500 deductible by January and my $7,500 out-of-pocket cap by February. This means that after I pay $7,500 in co-payments, Blue Cross covers 100% of my expenses for the rest of the year.

¬†¬†¬† The last hike was from $5,000 to $7,500 in 2004. My big fear now is that in order to make up for that $200,000 fine, Blue Cross will raise the out-of-pocket cap for my category of policy from $7,500 to $12,000 to $15,000 to $20,000 to God knows what. The ultimate aim would be for all but the richest sick patients to drop out because they can’t afford coverage anymore.

     Cancer patients also cost insurance companies money because new cancer treatments are very expensive. Last year, for instance, Blue Cross retroactively denied my doctor payment for a treatment called Avastin Рeven after two CT scans showed it had been working Рbecause at the time it was still technically experimental. (It has since been approved for lung cancer.)  

¬†¬†¬†¬†¬† I appealed to Blue Cross, and got a call from one of its medical directors, Dr. Richard Lehrfeld, who explained that he was upholding the retroactive denial because “If I keep garlic over my bed to keep away werewolves, and there aren’t werewolf attacks for five months… well, the logic is faulty there.”¬†

¬†¬†¬† Well, yes, I suppose the logic would be faulty there, because there are no such things as werewolves. But there is such a thing as lung cancer, so the werewolf analogy is what’s actually faulty. But I found it so amazing I just didn’t have the heart to argue.

¬†¬†¬† My doctor told me that Avastin’s maker, Genentech, would resupply his practice with the $10,000-a-pop treatment if Blue Cross wouldn’t pay. But I filed all the necessary paperwork to protest Blue Cross’s decision with the state of California anyway, just because I didn’t want the insurance company to get away with something I consider essentially indefensible.

¬†¬†¬†¬† The state’s decision? Two out of three oncologists felt the Avastin use was justified and therefore Blue Cross must pay, like it or not, and never mind all those arguments about werewolves. My hope is this might make it easier for other cancer patients without my resources (being treated by a top-notch doctor and practice, for instance) to get Blue Cross to pay for Avastin without an argument. But who knows.

¬†¬†¬† In any case, there’s something quite satisfying about knowing you’re absolutely right about something – and then learning that two out of three experts officially agree with you.

¬†¬†¬† Like most opinionated people, I often have the feeling that I’m absolutely right – and that those on the other side are absolutely wrong. But I don’t usually get the proof signed, sealed and delivered like this.

PajamasMedia Special Correspondent CATHERINE SEIPP writes the weekly “From the Left Coast” column for National Review Online, a monthly column for Independent Women’s Forum and freelances other places, such as the Los Angeles Times and Wall Street Journal op-ed pages. She previously wrote columns for: Buzz, Mediaweek, UPI, New York Press and Salon. Her work has also appeared in Reason, Penthouse, TV Guide, the National Post and Forbes.