Reading the fine print

I abruptly discovered last week that my health insurance plan does not cover the expenses of an unrelated donor.

The Duke transplant program tells donors that they are not responsible for the costs of the surgery. They say the recipients’ insurance is responsible. Except when it’s not, apparently (and ironically).

Duke Transplant:

The tests, the surgery, the hospital stay, and your return visit will not cost you directly. They are charged to the recipient’s insurance or Medicare.

My insurance:

The Plan does not cover any expenses related to the donation of organs, tissues, bone marrow or peripheral stem cells by live donors unless the donor is a living relative and the donor expenses were not covered under the donor’s health plan.

And the reason all of this is all suddenly acutely relevant…I’ve had a relative, who doesn’t fit the insurance policy’s definition of a relative, who has expressed interest in being a donor and may very well be a compatible donor.

Technicalities aside, it would seem that if the transplant team deems a donor’s kidney to be a likely match, that is all that should matter.

My nephrologist says that my insurance’s policy’s clause is “unconscionable”. For me, the discovery was a wicked punch to the gut. I allowed myself to think that perhaps my dialysis experience would be relatively brief, perhaps just a few months rather than 6-7 years. Following this policy, I’d need to not only find a willing and compatible donor, but I’d have to raise money for the surgery. When I was originally signed up for the transplant program, no one told me of relatives-only restriction. No one told my relative before my relative embarked on tests that weren’t covered.

The loophole…

My employer offers another plan that does not seem to have the relative-only restriction for transplants. I am told that the insurance will cover the donor’s surgery. But I cannot get a 100% guarantee because I have to be a policyholder first.

Normally, one is allowed to change plans only during open enrollment in October or due to a qualifying event (starting job, marriage, new baby). An HR benefits specialist has told me I can make the switch as long as I do so before January 1.

Now, I got the semi-definitive word from the transplant financial specialist around 4PM today. (Again, I can’t be 100% certain that this will really work until I’m a policyholder of the other policy). By the time I called the HR specialist, she was gone for the day…and possibly until January 4, as that’s what her voicemail indicated.

So, I have to hope that, either the HR benefits specialist is in tomorrow, or that someone else in HR can perform the same magic.

And all of this anxiety because of some fine-print on my insurance policy that I hadn’t noticed.

Call this Exhibit #84923827 of an insurance company playing doctor to the detriment of the patient. Not sure current health reform efforts would even do anything about this. It’s not like I am entitled to an almost-free kidney transplant. Folks on Medicare are. Geez…thank goodness we’re not getting Medicare for all…that would be horrible…

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4 thoughts on “Reading the fine print

  1. F^ck insurance companies.Another loophole Chisti took advantage of once… (though she needed help and assurance from her department boss) somehow she changed work to “part time” status for a month, then resumed full time status, and that somehow qualified as a “qualifying event”… I forget what she did that for, or how she insuranced herself (either got on my plan or cobra’d). She might remember more than I misremember on this. So this ‘relative’, does their insurance cover their side of the donation, and if so, how much would they be out of pocket (i.e. if needed how much would they need to be reimbursed)?

  2. Gidge, that’s a pretty good plan B if work people would let me do something like that. I guess plan C would be to raise some money. I pretty sure the donor’s insurance doesn’t cover anything, which makes some sense since it is elective surgery to have an organ removed at no benefit to the donor.

    Valerie, yeah, I had always thought I had excellent insurance, but now I guess I can consider myself under-insured.

  3. At least you can get a transplant at Duke. My wife’s insurance will only pay for one for her at UNC. We were trying to get on Charlotte’s waiting list (its shorter), but insurance will only pay for one hospital to do a transplant evaluation. We are looking at Medicare to see if it will pay to get on a second waiting list. Beware of unpleasant language from some insurance companies for patients after 30 months of dialysis. They almost all expect you to get Medicare as primary insurance by then. We are probably going to get Medicare, which we would have if Medicare didn’t kick her out after she had her transplant 3 years. I don’t know why Medicare doesn’t just pay it all forever, it isn’t like there is a cure for ESRD.

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