At least once or twice a week, one of our staff people will observe me at my phone, fist clenched, smoke rushing from both ears, my feathers clearly ruffled. I’m told I also sound a bit like Gilbert Gottfried, but I think that’s unfair. So what is it that’s setting me off?
Well, folks, it’s just me smoldering in conversation with a fellow physician or a nurse, sometimes even a pharmacist. And before you think I’m ‘fessing up a personality disorder you didn’t know about, let me add that these are not just random health professionals. These are the well-salaried professional prostitutes of insurance companies.
More than once I have resisted the urge to ask if they happen to be working while lying on their backs.
First, let me remind you of the health and disability insurance company game plan. The company collects your money (in the form of a premium). If you’re an individual policy holder, you pay 100%. If you’re part of a group, your employer covers a certain percent, you the rest. As long as you stay well you feel confident that you’re protected should you become ill or disabled. Most of the time, despite some unexpected out-of-pocket expenses, and considering its size (with hundreds of thousands of claims to process daily), the health insurance process goes remarkably smoothly.
Then the “uh-oh” occurs.
It’s the disability companies you have to watch out for
When Dr. Rubin and I were purchasing health insurance for our practice, our agent asked us about getting disability coverage, both short-term (three to six months) and long-term (usually six months to five years). “Why would we bother?” one of us said. “They never pay out benefits to anyone. When you try to make a claim, they make you crawl through the mud then they turn you down.” Wisely, the agent said “Let’s move on to property and casualty.”
Virtually every case of short-term disability (say a wrenched back, a slipped disc, a flare-up of fibromyalgia) is assigned a case manager, usually a nurse, who exists to obstruct your claim and humiliate you in the process. Here’s the usual sequence of events:
- You find yourself too ill to return to work.
- You gather the forms for short-term disability from the HR person at your job.
- You complete your part and then give the Medical Statement of Disability forms to me, which I complete and fax to the appropriate person.
Then…crickets. Nada. Nothing.
Remember, you’re too sick to work, but you marshal the strength to begin making follow-up phone calls to find out where your payment is. And humans never answer. You leave voices messages. Nobody calls you back.
Finally a connection is made. “Oh,” the nurse/manager chirps, “We do have your paperwork. Your doctor never sent his xyz (or filled the forms incorrectly, or whatever).” A total lie, of course, and we have the fax receipt to prove it. This is a standard delaying tactic and it can go on for weeks, while you’re both ill and rapidly going broke. You’re also under pressure to return to work.
So you fill out more forms, we photocopy your chart, dictate a narrative report. And the final results are rarely good news. No shortage of patients have told me “I could tell the nurse didn’t believe I was ill. All she wanted to do was look for loopholes so the company could get out of paying me.”
Finally, out of sheer financial desperation, you return to work, inadequately rested. You give up trying to collect, since it’s all you can do to get to the job and do what you’re being paid for. Phone them again and again, every day? You must be kidding.
The disability insurer has won again. And, if you can imagine, it’s even worse if you’re applying for long-term disability, which kicks in after short-term disability “benefits” expire. Usually this is a separate insurance company, so all the form filling and record transmissions begin anew. For long-term disability cases, companies usually assign both a doctor and a nurse. Not uncommonly, they also hire an investigative agency (yes, that’s right, a detective) to take photos of you if you go out shopping or walk your dog, “proving” you’re not really disabled if you can walk your dog.
Blood-boiling conversations with industry shills
It’s when I’m in conversation with the health professionals who supervise long-term claims that my blood boils. Since an insurance company profits by not paying benefits, it hires legions of these physicians and nurses to put a patina of professional expertise onto the denial process. This covers them legally should the claim ever to go to court (which it virtually never does). The vast majority of patients simply accept defeat. They’re tired and ill and it’s just too expensive to fight.
My conversations with these industry shills over the years have been amazing.
Insurance doc (ID): “You’re saying she can’t work because of pain. Can’t you give her a pain med?”
Me: “If I control her pain, the meds make her groggy. She can’t think.”
ID “Can you lower the dose? I don’t see how pain can’t be controlled. …and you mention ‘fatigue,’ I mean she just sits at a desk. Could you explain why somebody who’s tired can’t work? I mean we’re all tired aren’t we? Did you say she has fibromyalgia? I don’t see any blood tests here…”
Me: “There are no blood tests for fibromyalgia..”
ID: “Don’t they really think fibromyalgia is all psychological? That’s what I’ve read. I mean really. No x rays, no blood tests. I think she could go back to work…”
Me: “May I ask what you’re specialty is?”
ID: “I’m a retired radiologist, but I don’t think that’s relevant.”
Muckraker Upton Sinclair put it well more than 100 years ago…
“It is difficult to get a man to understand something when his salary depends on his not understanding it.”
A couple of weeks later, both the patient and I receive an official-looking letter documenting in a series of bullet points (including “no positive blood tests”) why the claim for disability has been rejected.
This is when I get really irritated.
I’ll call back the doctor or nurse who signed off on this letter even though I know we’ve pretty much lost the case. Nevertheless, out of sheer exasperation, I’ll remind them that when they applied to medical or nursing school, they likely wrote an essay about why they wanted to become a doctor or nurse. The most common sentence applicants write is “I want to help other people.” The second, “I want to make a positive difference in the world.”
So I have to call and ask, “Aren’t you bothered by what you’re doing? Doesn’t it affect you that you’re harming actual lives by selling yourself out like this?” (I naturally hold off uttering the ultimate blurt, “Do you do this job while you’re lying on your back?”)
The usual response is variation of “that’s uncalled for.”
“But it’s not uncalled for at all,” I tell them. “You’re getting a financial incentive to adversely affect people’s lives. This is bad karma.”
Nothing’s ever really gained. They virtually never reverse their decision. But at least I feel better.
And bad karma or not…I hope they feel worse.
David Edelberg, MD