“Angels have very nasty tempers.
Especially when they’re feeling righteous.”
I have had shoulder and neck problems for years. I think it's hereditary because my brother has had shoulder problems, too, and he's had to have shoulder replacement surgery. I, on the other hand, have had less-invasive surgery on both shoulders—one in 2005 and the other in 2008. I had an easier time recovering from the first surgery, and about three or four years ago, both shoulders started to give me problems again.
Last year, my orthopedic surgeon gave me a cortisone shot and a few exercises to help the left shoulder as it was the one that was hurting. He wanted an MRI, but the insurance company denied it. Lucky for me, the shot and exercises helped a lot.
Since last fall, my right shoulder has been bothering me again. I've seen my internist, and he's given me ibuprofen (Rx strength), though it's not helped. In May, he advised me to see my orthopedic surgeon, and I finally got in to see Dr. Kam a few weeks ago. He took x-rays and gave me the physical tests: Lift your arms. Put your arm behind your back. Push down on my hand. And so on.
"How do you feel about a cortisone shot?" he asked me.
"How do you think I feel?" I replied. "I think you know."
"It's the quickest way to relieve the pain," he said. I knew that. It didn't change my mind.
"I still hate it," I signed. "I'll still take it. Just make it fast."
So, he got that 10-foot long needle and shoved it into my shoulder. If you've had a cortisone shot, you know how much fun it isn't. If you haven't had one, count your blessings. "Give it two weeks," he told me, "and come back in. We'll go from there."
Two weeks later, I was still in pain, and he prescribed an MRI. I brought up the fact that Aetna had denied it the year before. "We've tried other things," he assured me. "They won't deny it this time."
So, I made the appointment (which took another two weeks), and this afternoon the radiologist's office called.
"Your appointment was canceled by your insurance company," the receptionist told me.
"Say what?" I exclaimed. "What do you mean by my insurance company canceled my appointment?"
"That's a nice way of saying they denied the procedure," he said. "You can have it if you pay for it out of pocket."
"Fat chance," I told him. "I'll call you back after I talk to the doctor's office."
I'm not going to go through all of that, but let me tell you that I was not happy. That said, I knew what was up. Allow me to explain.
When we moved to Atlanta in the mid-80s, I worked as a medical claims examiner for the now-defunct Mutual Benefit Life Insurance Company. I was a senior claims examiner and specialist, so I handled a lot of the more-involved claims and decided whether we would cover them or not. Those of us in that position knew that the unwritten rule was to deny, deny, deny...even when we knew the insured's procedure should be okayed. The reason? Most people will not appeal, so the insurance company wins. And, when people do appeal, the appeal takes time, so the premium stays in the company's pockets longer.
It's all about money, you know. We pay thousands in premiums annually so that if we need healthcare of any sort, the insurance company will pay for it. Most of the time, we really don't need it unless we have something minor. But there are times when we do need that coverage, and the insurance companies hold our lives and health in their proverbial hands.
As I said when I wrote about that obscene hospital bill from earlier this year, the insurance companies dictate our health care, not the doctors. Someone in an office who has neither ever seen us or even talked to us decides whether or not we need a certain procedure. That person, undoubtedly someone who did not go to medical school, gets to decide our care. Should I mention that that decision maker is working for the insurance company and not for us.
Think that's not true? Let me give you a couple of facts about Aetna...no explanation necessary.
• Aetna's fourth-quarter profits in 2015 rose 38% while their operating revenue increased 2.2%.
• Aetna CEO Mark Bertolini's compensation in 2015 amounted to $17.3 million. In 2014, it was a mere $15.1 million.
• Bertolini's bonus was paid at 153% of its target.
• Bertolini raised the starting pay at Aetna to $16/hour saying it would help production.
By all accounts, Bertolini is a nice guy. I've read quite a bit about him today, and I see that he's involved in a lot of good work and is so concerned about his employees that he's instituted programs to improve their health. I also looked at his Twitter page and saw that he has a sailboat, works with service dogs, goes to concerts, loves vacations, likes relaxing on a rooftop in Manhattan, and more.
Back to my personal saga with Aetna...
I was not happy about this latest denial. Five minutes after I wrote about the denial today on Twitter, I received a notification from the company asking me to follow them so they could private message me. I did, and they did. They wanted my personal info as well as the details to my case. I wrote them a quick email with all of the requested information, a question, and a promise:
My monthly premiums are in the neighborhood of $1300. What am I paying that for? So Mark Bertolini can go to Billy Joel concerts, have a relaxing evening on a rooftop in Manhattan, can sail through Mt. Desert Narrows? (Yes, I did look at his social media.) I used to be a claims examiner for a different company, and I know the games you play. I did not fight back last year, but I sure am going to do it this year....and it will not be only through this letter, the appeal, and Twitter.
Yes, angels have tempers, and when they flare, stay out of the way.
