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Wednesday, July 30, 2014 |  Madison, WI: 60.0° F  Fair
The Paper


Should have just suffered
Physicians Plus disallows coverage in time of need

Leon Bernido
Leon Bernido
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Editor's note: Michael Moore's Sicko argues that the nation's health-care crisis affects not just the uninsured but also the insured, who are subject to the predations of for-profit companies. Our invitation to readers to share their personal experiences with these companies yielded a number of replies. Here is one.

As a former emergency room staff member, I am mindful of the need to make reasonable use of ER services. And so it was only after long and anguished deliberation that I recently checked into the emergency room for an evaluation of severe, throbbing tooth pain.

I believe this visit was warranted because my jaw pain was affecting my sleep as well as my job performance as a registered nurse. I was very much mindful of the ibuprofen level in my system.

Approximately one month later, I received a $95 "facility charge" for use of the emergency room, and a separate bill for $229 from the "emergency medicine associate" (doctor's fee). Though my policy allows for emergency room visits with a $100 co-pay, my insurer, Physicians Plus, had denied coverage.

After sending a letter to the Physicians Plus grievance committee, I received a prompt response stating that Physicians Plus will not cover "dental services performed in an emergency room" and a copy of a "relevant policy," as Physicians Plus called it.

In this case, I believe the visit was medically appropriate and should have been covered. It's the kind of thing people have health insurance for. Does Physicians Plus think I went to the ER for the fun of it?

Physicians Plus, in my opinion, has never been good at providing pertinent information to new subscribers. Not everyone has access to the company's online database, and for those who do, deciphering and understanding what is covered and not covered is not easy.

And why shouldn't health-care providers, including emergency rooms, tell patients of policies that may result in the denial of coverage? The ER asks for proof of insurance during the admission process; why not tell people that the medical attention they seek is not covered?

Frankly, if I had known I'd be slapped with a $324 bill, I would have stayed home and suffered! Is that what Physicians Plus wants? Is that what its customers deserve?

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