Gaming the System -- How Insurance Companies Cover Their Bets

Health insurers are running a great big complicated business in which the well-being of their customers is only incidentally at issue. Just for starters, insurance policies are unreadable. Designed by actuaries and written by lawyers, the documentation explaining how 85% of Americans are supposedly "indemnified" for medical expenses is neither comprehensible nor particularly legible.
Perhaps insurance companies' healthy customers are untroubled by the low transparency score of their policies because they rarely submit claims. Maybe the many insured persons who do need medical attention primarily seek care from their plans' "preferred providers," so when medical professionals successfully claim their discounted portion of the fee, those patients can easily afford their "co-pay," regardless of "deductibles" and "lifetime caps."

Maybe they actually read the insurer's mystifying "explanation of benefits" form and, despite how little the company kicks in, are relieved to have a simple illness or require uncomplicated treatment. It is even possible that, to get routine medical care, ordinary working people from college professors to candlestick makers are content to regularly decipher and analyze claim forms, certificates of coverage, PPO limitations, eligibility charts and footnoted exceptions. They are the lucky ones.







Those who have the bad luck to require "out of network" medical services must pay full freight at the facility door, complete a claim, send a confounding invoice (replete with mysterious "diagnosis codes"), and take their chances that the unintelligible monolith cashing their monthly premiums will reimburse a fraction of it.
Ironically, many Americans are now saying this annoying and oppressive system is a good deal. They are in a happy fog hoping their child's unlucky coordination, chemistry, immune system or genetic makeup never demands medical assistance. Should catastrophe strike, they believe, perhaps naively, that their health insurance companies will back them up financially.