The Cost of Not Knowing the Rules

Insurance can be a tricky, tricky thing. Especially Health Insurance. I’m lucky, I have insurance through my employer. I’m very lucky, actually: They pay 100% of my monthly premiums.

But in April, we switched insurance. Well, kinda-sorta. It’s still through Anthem. But we joined a larger plan offered by our parent company (actually, our parent company’s parent company). Veiled in the details is the fact that the plan is self-insured for $x by the company. That means the company covers all medical expenses up to a certain point, and the insurance covers mainly just “catastrophic” events.

Does it matter? I’m not sure. Since we’ve switched plans, our little company has had a lot of large medical events happen. We’ve also had a lot of denials and other issues. It didn’t seem like we had so many issues under the old plan.

I thought I understood insurance plans pretty well. I’ve been an HR Manager before, dealing with all the details of health insurance. Once upon a time I also had my health and life insurance license. But I’m finding I don’t know as much as I thought. And what you don’t know can hurt you.

On Saturday, April 20th, I had a minor accident. I was helping my Mom move some items out of my sister’s shed when I stepped out onto an uneven paver. My ankle gave. It was tremendously painful for a few minutes. But, I hobbled around, and found I could put weight on it, so long as it was perfectly level and straight.

It hurt, but it didn’t swell, so I continued on with my day, trying to be easy on it. That night I iced and elevated it. The next day, it hurt, but was better. By the following day, it was feeling even better. It still hurt when I turned it, and stairs were terrible. But, it seemed to be healing.

Wednesday night I noticed I suddenly had a “cankle”. So much for not swelling! Since it was still sore, I called the doctor on Thursday, and made an appointment for Friday. She moved it around and said it was a sprain. It would probably take several weeks, but it should heal just fine. She told me to follow the standard sprain protocol (rest, ice, compress, elevate), and to come back in a week or so if it wasn’t doing better.

I thought it was getting better. I was still having issues, but it was better. Although, the combination of the BF making fun of me for being a wuss, and the fact that I don’t trust this doctor may have had a strong bearing on my thinking it was doing well.

I’m supposed to be looking for a new doctor. Since college I’ve been going to the same family practice, and they had a female doctor that I really liked. She left. So did the next one. And the next. None has gone on to do family medicine, so I wasn’t able to follow them to a new practice. So I’ve been seeing an odd woman, who likes to hug, talks in a sing-song voice, and wears so much makeup a street-walker would blush. On top of that, I don’t get the impression she’s that good of a doctor. She’s made a lot of mistakes in the few times I’ve seen her, from ordering tests incorrectly, to prescribing medications together that have adverse reactions, to prescribing medications for the wrong symptoms.

Anyways, six weeks after that doctor’s visit, I finally had to admit there might be a problem. So, I took the plunge, and scheduled an appointment with an orthopaedic doctor who specializes in feet and ankles, and is in my insurance network. He took an X-ray, and confirmed it isn’t broken. After a very thorough exam, he decided one of three things is wrong:

1) My calf muscle is extremely tight, which could be a result of trauma from the injury. The tightened muscle could be preventing the ankle from healing. In which case, physical therapy should do the trick.

2) I’ve done some serious damage to the ligaments. Depending on where and how bad the damage is, there’s a 50% chance I’ll need surgery. Otherwise, physical therapy should do the trick.

3) There’s a very small chance that I “dimpled” the cartilage. Surgery is the only way to fix it.

The only way to be sure was to have a MRI. So, a MRI was scheduled and completed. Regardless of which problem it turns out to be, none of them would have healed on their own. I should know tomorrow what the verdict is. In the mean time, I’ve been wearing an ankle stabilizing brace.

What I didn’t know? Our insurance is broken into two types: baseline and catastrophic. The baseline insurance kicks in first, and covers all the basics where you see $x in copay per visit. Baseline will typically cover a minor accident. Unless you don’t seek treatment within 48 hours, in which case it bumps into the catastrophic coverage.

Under catastrophic coverage, you have to meet your deductible before any services are covered. You do get the benefits of the discounted pricing. Once the deductible is met, it kicks into the % portion of the plan. In my case, that’s 20% that is my responsibility.

My deductible is only $700. It could be much worse. But, had I gotten the ankle looked at in the first 48 hours, I would overall be paying much less. How much less? I’m not sure. The bills haven’t started rolling in yet. On top of that, I have an Accident Plan through Aflac. Most of the reimbursements on that plan only kick in if you sought treatment within 72 hours.

I was always taught that you didn’t go to the doctor over every little bump and illness. Wait and see, and only seek treatment if it doesn’t get better on its own. Apparently that’s not the way things work anymore. My “wait and see” attitude could end up costing me more in the long run.

My newly established emergency fund is going to take a hit, especially adding in the “bug incident” from last week. It makes me very thankful that I have insurance, even if it doesn’t always work out the way I expect. I’m also very thankful to have the money available to get it fixed. You don’t realize how much mobility your ankle has until it hurts every time you move it!

– Ms. W

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