The Headaches of Health Insurance

In America there is an increasingly hostile relationship between those who have medical insurance and the companies that provide it. What do you do if you're one of the millions each year who's denied coverage for a procedure or a specific doctor?

Maria Muriente calls herself a "survivor" — of both breast cancer and a fight with her insurer. The conflict began last fall when, at age 33, she underwent a mastectomy.

"That was a big loss," says Muriente. "That was a blow to my femininity, you know? And it was scary. It was looking at mortality."

After her right breast was removed, a reconstructive surgeon - approved by her insurer - began the first of three painful operations. But while undergoing radiation and chemotherapy, Muriente received a letter from her insurer informing her that she'd have to change surgeons between operations because her current surgeon was "not participating in her benefit plan."

"I was very upset. Very upset," recalls Muriente.

As a result, Muriente became one of roughly 30 million Americans who each year has a dispute with a health insurer. The insurance industry says it’s simply trying to help employers and consumers keep a lid on skyrocketing health-care costs.

"Our community is trying to provide the broadest possible access at the lowest possible cost," says Karen Ignagni, president of America's Health Insurance Plans.

Do your research

From HMOs and PPOs to co-pays, deductibles, and payout caps, it's up to consumers to learn the system and make smart choices. Careful research is important before selecting a plan. Check out Consumer Reports for a ranking of HMOs and PPOs.

“Be certain that your health plan is going to have a lifetime cap that will allow you to receive the care you need if you are diagnosed with a serious illness such as cancer," says Nancy Davenport-Ennis, CEO of the Patient Advocate Foundation.

Patient advocates also urge consumers to:

• Read their insurance plan and learn what's covered
• If medical coverage is denied, appeal

If the answer is still no, contact a state insurance commission or a patient advocacy group. “And, in the end, if that doesn't work and the appeals process doesn't work, there's always a lawyer," counsels Twila Brase, president of the Citizens' Council on Health Care.

With health-care costs rising 10 percent to 25 percent in each of the last five years, health insurers are keeping a sharp eye on the bottom line — leaving many patients feeling left out.

"They don't see who I am. They see a number," says Muriente. Eventually, after much effort, she won her fight to allow the surgeon to continue his work and is now focused on recovering.