Private Health Insurance: Paying for What?

Two weeks ago I watched helplessly as my otherwise healthy 14-year-old daughter had an almost 3-minute seizure on the side of our bed.

We'd just eaten dinner and were cleaning up when my oldest son came in and said, "Mom, Charlotte’s acting weird." What else is new? I continued loading the dishwasher. A minute later all three boys came back. "Mom, she's acting really weird. She's in the closet." My 6-year-old, Charlie, tugged at my pants. "She's sad, Mom." I followed them down the hall to our room where we, indeed, found Charlotte in the closet, standing completely still and facing a rack of clothes.

"Charlotte." I tugged at her shoulder. She didn't move, stiff. "Charlotte" I said again, spinning her around. Her eyes wouldn't look at me, staring up and to the right. She didn't move, frozen in her own body, and my husband and I pulled her over to the bed where she sort of flopped down, still staring up and away. I ran to call 911, telling the boys to go into the other bedroom and try to stay quiet until we knew what was happening.

We had six emergency responders in our living room in less than five minutes, a pair of EMTs named Ron and John "like the surf shop," two paramedics, and two police officers. Charlotte had come to by this time, though my husband said just before she had she'd begun to twitch, more like a typical seizure, before waking up and begging to go to sleep.

“I’m so tired, Mom. Please, can’t I just go to bed?”

We didn't let her. They asked her questions, simple ones like "where do you live?" "what's your mother's name?" "what is your favorite food?" She, always the "polite Canadian," as we call her, apologized for not knowing the answers, assuring the first responders she would try harder. They smiled, kept her awake, and packed her into the back of an ambulance for the short ride to Hackensack Medical Center.

We spent a few hours in the ER before they admitted her to the pediatric epilepsy unit, where they attached wires and IVs, an EEG cap to her head for the next 24 hours, followed by an MRI and multiple urine tests.

Side note: if you're going to have a medical emergency, be sure not to eat a poppyseed muffin the morning of. No one will believe you.

We kept asking when she could go home, but they warned us that this was a serious situation, and until her tests came back to say so, she was not safe to go home. The doctors and nurses were kind, they were thorough, and they spoiled her with Star Wars crafts and LEGO sets (it was May the 4th), letting her eat and watch whatever she wanted as she powered through sleep-deprivation tests, and light tests, and every kind of tests. My husband and I swapped places so that one or the other could go to work, and somehow we all survived. It wasn't an unpleasant experience, all told, other than the fear that your child is sick and life might change from this day forward.

But in a moment of terror, of upset, of ultimate love for my child and confusion as to why this happened to her, a totally healthy kid, we received a letter in the mail. It was dated while Charlotte was still strapped to her IV in the peds unit.

The letter was a denial of care from Aetna, our medical insurance provider.

"After careful review of clinical guidelines and your health plan coverage, we denied coverage for the health care service(s) shown in the enclosed letter." - Aetna Inc.

We were shell-shocked. Charlotte's case was being denied coverage because it was deemed "medically unnecessary." A 3-minute seizure in an otherwise healthy kid.

Ambulance - unnecessary.

Hospital - unnecessary.

EEG testing - unnecessary.

MRI - unnecessary.

I called the hospital and asked what the heck was going on, and they had no answers, but were just as confused as I considering they hadn't even billed the insurance. The paperwork hadn't even gone out, yet Aetna somehow found it in their power "after careful review" to deny the coverage.

I posted about it on Twitter and received a pretty massive response, including offers to help, either financially or by writing letters to the company. One of those was Aetna themselves, who reached out to me personally to assure me that:

"Based on a clinical review, it was determined that the services provided to the member did not require inpatient care. This does not mean any services were denied; it only affects how the plan benefits are applied and the level of care covered (Emergency Room/Observation vs. Inpatient care)." - Aetna Inc.

Oh, phew, thank goodness. Services weren't denied by the hospital (no shit), they were just determined to be unnecessary, and would be billed accordingly.

*Wipes brow*

My daughter is better today. Whatever it was, seems to have passed, and thankfully didn't show up on any of the tests. She'll follow up with a pediatric neurologist for the next few years to make sure we didn't miss anything, but is otherwise able to finish up a normal 8th grade year, participate in marching band, hang out with her friends, and graduate next month.

Meanwhile, Aetna sent us a pseudo-apology.

"The authorization request was submitted in error."

Currently there is a class-action lawsuit against United Healthcare for using AI to issue denials in coverage with a 90% error rate. So it would seem, they are not the only ones.

We live in a nation that survives paycheck to (almost) paycheck. Very few of us have savings, if health coverage at all. The "lucky" ones shell out hundreds of dollars each month to cover basic medical needs for our families. But when we need it, like really need it, where are these companies to catch us when we fall? Too busy pocketing hundreds of millions of dollars on behalf of sick Americans. Too busy asking ChatGPT:

“How can I deny coverage?”

Stay well, it's all we can afford to do.

Ellie is an author, editor, and small-business owner, and works with filmmakers, podcasts, and journalists all over the world. She lives with her family just outside of New York City.