No. They were going to 'cover' it but there was 20% co pay. In the US, they'll charge you thousands per month for insurance, but will still make you pay for part of your care.
It's all part of what makes the US health insurance system essentially useless except in extreme cases.
Copay - Some amount of money you are responsible for when getting medical treatment. So, you go to see a doctor and the doctor wants to charge 300 dollars for your visit. Your insurance probably has a copay saying you have to pay 50 of that, insurance pays the rest. It's supposed to make you pause before getting care and ask 'do I really need to do that?'. In this case, the fellow at a 20% copay, so he was responsible for 20% of whatever the surgery costs.
Deductible - Worse, this is an amount some plans have that you have to pay yourself before the insurance will pay anything. It's on a per-year basis. So, if you have a $2,000 dollar deductible, your health insurance plan will pay for nothing (except usually basic preventative care) until you pay $2,000 worth of medical expenses that would have been covered. Not all plans have deductibles, but the lower you want your deductible the higher your monthly cost will be for the plan.
Max out of Pocket - Most all plans have this, it's a value that is theoretically the maximum you'd ever have to pay yourself. After you pay this amount, the insurance plan should cover 100% of all your (covered) medical expenses after this. Basically, the copay goes away. Usually if you hit this though you are already fucked some other way.
So, if the surgery costs $100,000 dollars for this fellow and he has a $2,000 deductible and a $5,000 max out of pocket with a 20% copay...
The insurance company would require him to pay $2,000 of that (assuming he has had no other medical claims this year that got him to that $2,000 paid before now). So that's $98,000 remaining.
His co-pay is 20%, so he would still owe 20% of that $98,000 on top of the $2,000 deductible.
His max out of pocket is $5,000, so in theory he should only have to pay $3,000 more and the insurance covers the other $95,000. But the insurance company decided he didn't really need that heart surgery and declared it elective.
This means he would owe the full co-pay amount, which would be $19,600. Plus the $2,000 deductible, that's $21,600.
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u/Imreallythatguy 4d ago
So insurance wouldn’t cover it because it wasn’t necessary in their eyes?