There are two sides to receiving health care in the United States: one is finding, and getting, the actual care itself; the other is dueling with insurance companies to make sure they pay what they owe.
It is difficult enough to find top-notch care, so the fact that we in the United States are regularly required to fight against our own insurance companies — which are, in theory, supposed to be overseeing our well-being — is frustrating and even shameful. It’s a topic I wrote about more than two years ago, when I began to see firsthand how fractured the health care system is.
Anyone who faces this kind of patient vs. insurance situation needs inspiration. So here’s a little story to show that this battle is winnable and that the fight is worth fighting:
Last December, I received the last of my dental implants. As I found out, there is a bizarre relationship between dental implants and health insurance companies in this country. Even though implants are increasingly common, health insurance companies often do not cover them. And those that do cover them will typically not pay for the whole thing. The usual procedure is for insurance to pay for the implant post — which is drilled into the jawbone and anchors the new tooth — and the piece (called an abutment) that attaches the crown to the post, but not to pay for the crown. The crown is the responsibility of dental insurance, according to their line of thinking.
Why would a health insurer pay for only part of a solution but absolve itself of the rest?
That is what I was consistently told is standard procedure by a handful of representatives of my insurance company, Blue Cross Blue Shield, during numerous phone calls over the course of many months.
I never accepted that as a reasonable answer.
During one conversation earlier this year with one of those representatives, I was given a shred of hope. I explained the circumstances of my case and reasoned that because BCBS paid for the implant posts, it also should cover the cost of the crowns. Neither the posts nor the crowns are any good on their own, I said; they are part of a cohesive whole and BCBS should treat them as such.
Even though the rep admitted she’d never heard of a case where BCBS paid for crowns, she said it wouldn’t hurt to submit a claim and see what happens. Why not?
After waiting for late-arriving paperwork from my dentist, I mailed my claim in March. BCBS said I should expect to hear back in 30 days, but that didn’t happen. Around the 30-day mark I called for an update. The representative had no idea what the status of my claim was, but she said she would help it along. She also added to the chorus of “I’ve never heard of anyone getting crowns covered.” It didn’t look good.
While I was on vacation, BCBS called and left a message at my work. Hopeful, I dialed.
“Hey, Jonathan, this is [name redacted] from Blue Cross and Blue Shield. …. I did want to let you know that the review came back and according to everything that I’ve read, it doesn’t look like we’re going to cover the crown portion of your, you know, implant surgery. You are more than welcome to call us back if you want further details. Um, I’m sorry to have to give you this bad news, but uh, give us a call, like I said, if you want more details. Have a great day. Bye-bye.”
A day or two later, I received an email from BCBS saying the claim had been finalized. Without a clear idea of why I wanted more punishment, I logged in to my account. I couldn’t find the claim anywhere. Just as well.
I got home that night and found a letter that had arrived from the insurer. I thought about tossing it directly into the recycle bin, but with nothing better to do at that moment, I ripped it open.
The first page was a chart related to my claim. One line caught my eye within seconds: “Total benefits approved: $2,623.76.”
Below that: “Payment of $2,623.76 was made to JONATHAN C FOGG on 05-05-16.”
“HAH!” I shouted.
I flipped through to the last page. It was a check … in the amount of $3,393.76. Why was it more than the cover page said it would be? I don’t know, but it doesn’t matter. It’s gravy.
I’m reminded of some incredibly inspirational writing I came across this week. I was reading an article compiling the greatest graduation speeches ever delivered, and No. 2 on the list was Steve Jobs’ address at Stanford University in 2005 (which happens to be the same year I graduated from Susquehanna University):
“Don’t be trapped by dogma, which is living with the results of other people’s thinking,” Jobs told the students. “Don’t let the noise of others’ opinions drown out your own inner voice. And most important, have the courage to follow your heart and intuition.”
I fought the conventional wisdom of an insurance company and won. And after two-plus years of being told by insurance reps and secretaries, and even my own dentists and oral surgeon, that health insurance doesn’t cover crowns, after receiving the “sorry, we don’t cover that” voicemail, I refused to be trapped by dogma and other people’s definition of what’s right.
I deposited the check today. It was the most fulfilling trip to the bank I’ve ever made.