The health insurance debacle…Not everything is as it seems…

What a face!

“Fascinating Fact of the Day About Ireland”
The Irish famine in the 1840s led to a population decline of two million people because of immigration and starvation.”

When we purchased our annual international health insurance policy from a company in the UK almost seven years ago, we’d hoped we’d never have to make a claim. The policy was issued for “major medical” only, meaning it covered hospital stays, surgeries with in-hospital treatment, and medication but not routine doctor appointments, urgent care facilities, or prescription drugs.

The co-pay for the hospitalization is Euro 1763, US $2000, per hospital admission. Since February this year, I’ve had three hospital admissions and four surgeries (two leg surgeries in one five-day hospital admission).  

At the time of the first admission, we paid out-of-pocket, the sum of ZAR 80000, US $5348, Euro 4715, for the estimated cost of the first visit to “theatre” for the angiogram including one overnight stay. At the time, the hospital’s billing department was diligently attempting to get our insurance company to pay, to no avail.

During the subsequent surgery, the cardiac bypass, the insurance company hedged for days but finally got their funding subsidiary to pay a portion of the hospital bill excluding all the doctor bills.  

Our insurance company was attempting to claim I had a pre-existing heart condition I hadn’t disclosed at the time of the application in 2012. This is simply not true.  

Sheep grazing on a hillside.

Sure I took a low dose hypertensive drug for a mild case of heredity high blood pressure, but I had disclosed this at the time of the application.  My blood pressure has been totally under control for the past 20 years, usually running around 110/68, certainly not a concern.

Besides, would we be traveling the world, often embarking on strenuous activities, if I had a known heart condition?  Hardly. We had no idea. We’d have taken immediate action rather than risk my having a life-threatening cardiac event had we known.

Then, on March 29, 2019, we visited the cardiothoracic surgeon for a routine post-cardiac bypass surgery exam at which point when he examined the condition of my legs, he immediately arranged an appointment with a plastic surgeon with excellent “wound care” experience.  

Within hours, I was immediately admitted to the hospital, having the first of two leg surgeries a few days apart.  But, before admission, we spent two very stressful hours, trying to get the insurance company to pay the required ZAR 130000, US $8690, Euro 7662. Here again, we had to pay out of pocket when the insurance company wouldn’t come through.

I spent hours on my phone attempting to get the insurance company to pay. Once again, they used all the excuses in the world to avoid paying. They said we should go ahead and pay out of pocket and later file claims, which we’ve done, again to no response.

Since we’d already paid the plastic surgeon’s bill out-of-pocket, in the above ZAR 130000, we had no outstanding bill with her. Plus, we’d paid the ZAR 80000 out-of-pocket for the first hospital admission to the cardiologist.

Two adult Connemara ponies and a youngster.

Remaining have been the bills for the anesthesiologist, surgical technicians, and most importantly, the cardiothoracic surgeon who’d performed the bypass surgery.

Need I say, dealing with the insurance company and their representatives to get these outstanding bills paid has been an outrageously stressful situation. When I was dealing with this, I could feel my heart pounding in dire frustration.

Why didn’t Tom handle this? We all have our specific skills. Negotiating and handling the endless flow of paperwork was simply not Tom’s forte, and it hardly felt like mine during recovery.

I recall being on the phone with the insurance company while I was in ICU for eight days and immediately upon returning to Marloth Park after the surgery when I was in rough shape for many weeks.

So, where are we now? With their refusal to pay they have claimed they are awaiting my medical records for the past 20 years which I have since verified are in their hands.

Now, bit by bit, bill by bill, we are negotiating with doctors requesting they accept a discounted payment from us. This is standard practice in the medical business when companies often deal with reduced fees for services, especially in the US for Medicare and Medicaid and national health insurance (NHS) as provided to citizens of the country of South Africa.

A beautiful sunset from the garden.

We’re almost done paying with one outstanding payment to negotiate, which we’ll hopefully resolve by tomorrow. At that point, we’ll submit a few more claims and wait and wait and wait…to see if the insurance company will ever reimburse us.

In the meantime, we’ve had no choice but to keep the policy in effect, although they doubled the premium after the surgery. No company will insure me other than Medicare in the US which I may have no choice but to re-instate once all of this is resolved.  

It is ill-advised to cancel the policy now until all of the claims are resolved or, we give up hoping to be reimbursed. While in the US in November, we’re considering signing me up for Medicare which doesn’t pay for any medical treatment outside the US but if I need non-emergency treatment, we can always fly back to the US for such treatment. If it’s an emergency outside the US…we’re in big trouble.

Many may say, “stop traveling and return to live in the US.” We have no interest in doing this. We have a lot of the world left to see and are not forfeiting the joy and happiness we continue to experience in our travels.  

If and when the time comes, we can no longer travel due to medical issues, we’ll decide at that time.  We now realize the delicate balance of life itself, more than ever, and how and why we should live it to the fullest.  

Many don’t get this decision but, we do, and in the long run, that’s all that matters. We’ll continue to update the progress on this frustrating situation as we continue. Right now, our focus is on healing, recovery, and putting all this stress behind us.

Have a pleasant day and evening wherever you may be.

Photo from one year ago today, June 9, 2018:

Water spouted out of his mouth after he took a big gulp of water. For more photos, please click here.

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