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Comment by whymauri | Hacker News Reader

A close friend of mine's wife paid their health insurance for decades, without fail. Their employer changed the insurance provider without notification, but somehow they continued paying the wrong provider. She recently got breast cancer, and now the new provider is denying all claims on the basis that she was paying the wrong provider.

They are basically screwed now after maintaining a non-deliquent relationship with their healthcare provider for longer than I've been alive. If this is not emblematic of what's wrong with our healthcare... IDK what is.

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> somehow they continued paying the wrong provider

How does it happen that the wrong (old) provider still accepts money if they no longer cover you? Can this be used as a legal argument that the old provider is on the hook for coverage since they continued taking the money?

"After review, it seems you are no longer eligible for our services. Have a refund"

My friend paid his health insurance for years. Got diagnosed with cancer (leukemia). Hospital said treatment would cost $750k. Insurance told him to go fuck himself and isn't covering anything.

Do you know what the treatment option(s) were? That seems extremely expensive even for cancer. Makes me wonder what my family plan's maximums are.

I do not. They managed to raise about $80k through GoFundMe, and he just found a donor after months of looking. Assuming he will be in debt for the rest of his life, if he lives.

Doesn’t seem unrealistic for a list price. List price for a standard baby delivery and 3 day recovery around here can be up to ~$80k. Of course, the real insurance contracted price is $10k. The list prices are completely absurd, and it’s even more absurd that hospitals try to collect that clearly fictional amount from patients without good coverage.

After ACA there are no lifetime maximums. If it’s an FDA approved treatment which he is eligible for (e.g. there are not other first line treatments which should be tried first) then AFAIK an insurance company cannot simply refuse to pay.

Another option is to move to a Medicare expansion state and stop working, which will allow you to immediately qualify for free health care with generally some of the best coverage you can get.

Insurance companies are free to not cover an FDA approved product. CVS publishes a list every year, although they tend to either be the branded drug when a generic is available or a drug where there are as effective, but cheaper products are available.

It’s a cost versus benefit analysis and no different than what you see in single payer systems.

I will say from experience that oncology is one therapeutic area where payers wield much less control. Insurers don't like bad press and denying cancer drugs is a great way to end up in the NY Times. That said, if a drug is regarded as "experimental" (either the FDA hasn't approved it for that type of cancer OR there is limited data to suggest it works) they will say "no".

https://www.caremark.com/portal/asset/Formulary_Exclusion_Dr...

Insurance companies certainly can have formularies. I noticed that there aren't any drugs on the excluded list that don't have alternatives listed.

When we change insurance plans my kids have to change the brand name of insulin they get. Humolog, Admelog, etc. But the insurance company can't decide that they won't pay for fast-acting and slow-acting insulin. And if there is a medical reason a doctor will sign off on that indicates a specific brand is required, I believe that you can generally get even excluded medicines covered.

Can insurance companies refuse to cover an FDA approved drug that doesn't have a reasonable substitute? OP discussed treatment for leukemia. An ACA plan should cover approved treatments for leukemia, but it might not cover, e.g. the latest CAR-T treatment if it's still in Phase 3. You would need to get into the study, in which case treatment would be free.

Just to be clear, you mean that the insurance company is not allowed to set a maximum lifetime (or annual, for that matter) limit beyond which they will stop paying expenses, correct? P

Under an ACA approved plan, that is correct.

Interesting. Is a defense mechanism to this then to use the healthcare at least once every period you're comfortable with? I have Kaiser Platinum and looks like I'm about to start requesting monthly tests on things.

Co-pay is about $10, so for $10 a month I can guarantee my healthcare is working.

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