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US Patients Fight Incomplete Health Insurance Coverage


Part of 3 of VOA's 5-part series on Health Care

About 65 percent of Americans have private health insurance that is supposed to pay for anything from routine doctor visits to serious illnesses. But even people with some of the best policies find out too late that insurers may refuse to pay for needed medical procedures.

Unexpected expense

Aram Williams is like many two-year-olds: he is active, happy and works hard to keep up with his older brother. It is hard to imagine that a year ago he was diagnosed with a congenital heart defect that would require open-heart surgery to fix.

Aram's mom, Jarene, says what started as a hospital trip for a baby with the flu, quickly turned into something more dire. She says it was not an easy road, especially getting insurance to cover the hospital bills.

"Well the hospital we went to accepted our insurance, but various specialists at the hospital did not," Williams said. "So we started getting these surprise bills. I said wait a minute. We are insured."

The family's insurance helped pay for the enormous costs associated with the surgery, hospital visits and Aram's recovery. But the situation changed when his doctor prescribed the common drug Viagra to treat a lung condition resulting from the surgery.

"So his doctor wrote a full letter explaining why he needed it, and we sent his medical records. And they [the insurance company] still rejected it. And it is a very expensive medication," she said.

With no help from the insurer, Aram's family had to pay about $600 a month for the drug. That was in addition to the $5,000 a year in doctor visits they were already paying.

Negotiating for needed care

Like Aram, many other patients find themselves negotiating with an insurance company to get the health care they need.

Dr. David Woolsey says the financial problem is one he sees every day in the emergency room at Jackson Memorial Hospital in Miami.

"One of the beauties of working where I do is I am in a hospital that has every facility you can have, if there is anything someone needs you can do it," he said. "And I spend half my time talking to people about why they are not going to get it, what it is going to cost, and what should be done, but cannot."

Protecting the sick

Advocates of health care reform say too often money is the factor in whether someone gets life-saving care or not. A key goal of reform is to make certain insurers are covering their patients, and that they do not cut policies to sick people.

Under the current system, Dr. Woolsey says even patients with health coverage worry more about their savings, than their health.

"There cannot be that question in people's mind of, 'Can I afford to go get this done," he said.

Not everyone thinks the reform bill will guarantee more health coverage. Critics say more government pressure on private insurers could hurt people who are happy with their existing coverage, such as reform protester Judy Smith.

"It could be affected, because my husband is employed, it [our health coverage] could go away. I understand that," Smith said.

Journey is far from over

For Aram, the insurer finally offered to pay for his Viagra only after his mother spoke out publicly. He no longer needs the drug, but his mother says their medical journey is far from over.

"We are still at risk of incredible debt from being able to pay for our portion of our child's care, even though we are insured. That is a little scary," she admitted.

Aram's family also worries the insurance company could drop him from the policy, because of rising costs. Jarene supports health care reform in part to make sure insurers could not do that to her family or someone else.

Jarene is glad her family has the insurance they do, and she knows other families are not as fortunate.

"There were a few hoops I had to jump through, but ultimately his life was saved and he did get the care he needed," she said. "I would like to know that other American families can have that same access."

Issues like these are at stake as reform measures move forward in Congress in coming weeks.

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