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Rob Kall: So, would you say then that it's part of the business model of the health insurance industry to do a sloppy job of accepting insurance money from people for years even...if there's a problem, they can get out of their expected responsibility to cover an illness, because they didn't do their job in the beginning of informing the patient that there was a question or a problem with the way they registered with them.
Wendell Potter: Oh, that's exactly right, it's done retroactively, and it happens many, many times. And it's done consciously, as some of the insurers were even paying bonuses to employees to scour applications and find things that would enable them to deny a policy.
Rob Kall: Would they use that information immediately, or would they save it and wait until the patient got sick?
Wendell Potter: Usually, it would be when a person got sick, and more than likely, they would continue to let you pay your premiums. Most people, remember, don't use their insurance all that much. Fortunately, most people are healthy and don't get in accidents, so you keep paying the premiums hoping the insurance will be there if you need it. So that's typically what happens, is after you do need it and you file a claim, that you're often subjecting yourself to the possibility of being purged, or not purged in this case, but your policy being rescinded and you would be left with the responsibility of paying all of your medical costs.
Rob Kall: Rescinded...?
Wendell Potter: Rescinded...
Rob Kall: The faith that you had insurance, that your life would go on smoothly because you were insured, has been rescinded.
Wendell Potter: Correct.
Rob Kall: Now,
you also testified that there's a lot of secrecy and a lack of transparency,
intentional, with these insurance companies. Could you talk about that
a bit?
Wendell Potter: Well, that's true. The first priority, as I said earlier, is to make a profit and to extend as much money as possible to shareholders. Developing materials that are clear and understandable is not a priority. In fact, it often benefits an insurance company if they can obscure the terms of the policy and either mislead or just not even tell people what the coverage limits are on certain policies, for example. And often, when you do get some coverage information from an insurance company, it's so hard to understand.
Like I said, I was in the insurance industry for twenty years, and I have a pretty good education and a lot of understanding of how the insurance companies operate, and was actually the head of corporate communications. I myself had a heck of a time understanding something called the "Explanation of Benefits" statement that they'll send you when you get care and to explain, try to explain how much they paid and how much is your responsibility to pay. It's very, very...very confusing, very complex.
Rob Kall: They make it something you don't want to look at, and...I run a small business, and we have health insurance. And so I get these documents, the "Explanation of Benefits." I'm not sure if it's every subscriber or every person who's insured that gets them, or if it just comes to the head of the company. How does that work?
Wendell Potter: Well, it usually goes to the individual policyholder. For example, if you are the head of the household, you probably would get it mailed to you, but if some member of your family had gotten care, you would get the information about your family member. But you're right, it's very hard to understand, and I think most people when they see these, and from the point of view when I thought about it, was so baffling, you just file them away, or throw them away.
Rob Kall: When I see them, I usually see really obscure treatments and illnesses on the front page. I think, "That doesn't apply to me," and I kind of flip through, and there's a lot of gobbledy-gook and boiler-plate legalese, and I'm guessing that maybe if there's anything important, they embed it somewhere in the middle so you don't even notice it.
Wendell Potter: Well, that's true; there are a lot of codes on these things. And you're right; it's kind of a mix of medical jargon and codes and legalese, and just plain bad writing. It's almost impossible to figure those things out.
Rob Kall: So I can think of two simple rules that Congress could pass regardless of the kind of insurance they have. One, insurance companies should have thirty or sixty or ninety days, or something like that, to reject somebody because they didn't provide all of their information. And then they can't reject them later on after they've taken all their money when they've been healthy. That ought to be a simple thing that could be passed, that would protect a lot of people. And the other is, that notification should be in plain, simple English, and issues related to the patient should be up front, in the beginning. I know enough about databases, so that's an easy thing to do.
