Dogs & Trainwrecks: How Big Insurance Sees Us

When I was up
You would always come round
But when I needed a friend
Oh, you could never be found

I got a hole
Where my heart used to be
I wouldn't treat a dog, no, no
The way you treated me

Cher, "I Wouldn't Treat a Dog the Way You Treated Me"

Hey, Sen. Landrieu [1]. Here's another American who just wants "free health care." Of course, that depends on your perspective.

As far as his private insurance company is concerned -- you know, that "private market" you're so keen on protecting? --he's a "dog" siphoning off their potential profits. but as far as Ian Pearl is concerned [2], a guy with muscular distrophy who just wants to live.

I am not a "dog." That's what health insurance executives called me because I have a disease. I'm also not a "trainwreck," another term they used for members like me.

Soon after I was born in 1972, I was diagnosed with muscular dystrophy. By the time I was six years old, I was confined to a wheelchair. Doctors doubted I would survive, but I inherited my parents' determination, and I proved them wrong.

His insurance company would eventually come to understand the strength of the Pearl family's determination.

Despite being confined to a wheelchair by the time he was six-years old, Pearl not only survived, he thrived. He entered college in 1990, only to suffer a setback in his condition.

[A]t 19, I had a severe setback and I was confronted with a stark choice. My survival would require a machine to breathe and round-the-clock nursing care.

A breathing machine usually means life in a nursing facility. But my father's small business had health insurance from Guardian Life Insurance Co., which promised "Solutions for Life." The health policy had no lifetime benefit cap and covered home nursing care. Relying on that contract with a 149-year-old company, I decided to go on a mechanical ventilator for the rest of my life.

Since then, I've endured life-threatening medical complications and long hospitalizations. I've lost my privacy and ability to travel. But I never regretted my decision to live, to continue to learn and write, and to share in the lives of family and friends.

He and his family would endure much more, as the insurance company — according to Pearl — search desperately for an excuse to drop his policy, including hiring private investigators to search for evidence to cancel his policy. They found none. And then there was the law: it was illegal to cancel the plans of individual policyholders with serious, chronic illnesses. So, the insurance company found a way around it [3].

Rather than continue to pay for Ian Pearl's million dollar medical treatments, one insurance company has decided to end certain lines of coverage altogether, reports William Ehart of the Washington Times. Pearl, 37, suffers from Type II spinal muscular dystrophy, and has been using a wheel chair and connected to a breathing tube for most of his life. Patients with his type of muscular dystrophy rarely live past infancy, but Peal credits his vitality to the care he has received all his life.

On December 1 his insurer, Guardian, is discontinuing a portion of its coverage, which will effectively kill him. Without his extensive coverage Pearl will be admitted to a state hospital under Medicaid, with less treatment. Pearl's mother said that in a state hospital her son would be lucky to live more than a few weeks. Pearl's plan, as of now, covers 24-hour home nursing, which Medicaid, and the vast majority of plans, do not.

"This is attempted murder" said his father, Warren, "the insurance companies are cheating in order to have obscene profits." Last year Guardian reported $437 million profits, up 50 percent from 2007.

The Pearl family sued, and what they found out added insult to injury [4].

Barred from discriminating against individuals who submit large claims for payment, Guardian has opted to simply cancel the lines of insurance that provide the coverage Ian needs in all the various states where they do business – all just to avoid paying for Ian’s care.

Believing that this could not possibly be legal, Ian and his parents brought an action in federal court to stop the cancellation. The court ruled that the company had not violated ERISA because it canceled entire policy lines – not just Ian’s. The Pearls also claimed that Guardian violated HIPAA. The court ruled that only the Dept. of Health and Human services can enforce HIPAA and that private citizens cannot sue under it.

Following the court’s decision, Pearl appealed to HHW under the Bush Administration but to no avail. He is now petitioning HHW once again, hoping for a better result from the current administration.

And their lawsuit revealed what the insurance company executives really thought about their policyholders who actually had the greatest need of medical care and coverage that would give them access to care.

Our lawsuit uncovered insurance company documents that confirmed my suspicion that I'm a target of discrimination. The documents revealed Guardian had compiled a "hit list" of its costliest members, including patients with muscular dystrophy, multiple sclerosis, brain injury, and paralysis. Guardian executives referred to us all as "dogs" and "trainwrecks," and they debated how and when to dump us from the rolls. Laws prohibited the cancellation of the individual members with serious chronic health problems, so Guardian opted to cancel the plan for all members of this specific health plan in New York, an action that violates federal law.

Although my medical costs constituted a minuscule fraction of Guardian's profits, the company had been trying for 15 years to sidestep its obligations to me. The insurer hired private investigators who searched in vain for evidence to justify canceling the policy. Guardian had similarly targeted the other "dogs" without success. Finally, Guardian launched the unprecedented strategy of withdrawing an established plan throughout an entire state in order to discontinue a few costly members.

Specifically, Guardian's vice president floated the idea that the company could "eliminate this entire block to get rid of a couple of dogs." [5]

In an e-mail to four other Guardian executives entered into evidence in the Pearls' suit, company Vice President Tim Birely discussed how the company could "eliminate this entire block to get rid of the few dogs."

He concluded, "Paul [Saylor], keep in mind that my intent is to be as narrow and laser-like as possible. We may need to broaden some things in NY due to state of domicile and some historical [nonsense] with some of these policyholders."

Asked about the use of the phrases such as "get rid of" and "dogs," Guardian spokesman Richard Jones said, "I'm not aware of any language related to any of the things that you just mentioned, no."

He said plans such as Mr. Pearl's had simply become too expensive to market to employers.

"We certainly sympathize with [Mr. Pearl's]'s condition. As a business, though, we have to offer plans that enough customers want," Mr. Jones said.

You see, Senator, Pearl's case is one of those in which the profit model breaks down. At some point, it isn't profitable to provide him with care. And Guardian, like other insurance companies, will say "We aren't denying care. We're simply denying coverage." Pearl, and the other policyholders like him are free to seek coverage elsewhere — if they can find insurance companies that will accept new applicants with pre-existing conditions, and that offer coverage for the care they need at an affordable cost.

Given the likelihood of that, they can always resort to bake sales, car washes and tin cans at convenience stores [6].

Pearl's isn't the only such story. Bill Caudle [7], who enlisted in the Army at 39 to get insurance to pay for treatments for his wife's ovarian cancer, is another.

Bill Caudle, 39, enlisted in the Army so that he could get health insurance help pay for his wife's ovarian cancer treatment, reports Mark Johnson of the Milwaukee Journal Sentinel. Bill was laid off from his job at a plastics company in March, where he had worked for 20 years, and searched for a new job for a few months before signing up so that his wife and high school sweetheart, Michelle, would be guaranteed chemotherapy. On their own, the Caudles' insurance cost them $1,370 each month, which they could not afford on Michelle's part-time salary at a fast food restaurant.

The four-year commitment means Bill will miss all of his youngest daughter's four years of high school. Chelsea, the daughter, cried when her mother told her. Bill left for processing and basic training October 6. The next day, once he was officially processed, his Army health coverage started.

Dawn Smith's [8] is another one.

One such example is Dawn Smith, a young woman who suffers from two brain tumors. Dawn has been continuously denied the medical care that doctors say is critical to save her life. Three doctors from three renowned health care systems in the metro Atlanta area informed Dawn that her “only chance for a cure was to see a specialist at Cleveland Clinic or Washington University’s Center for Advanced Medicine.” Yet, her health insurance company, CIGNA, has denied these essential treatments.

Dawn calls the insurance company callous and expresses her feeling of complete “insignificance,” when being repeatedly denied care after she was diagnosed with the brain tumors in 2005 and 2007. Dawn had religiously paid her insurance premiums for six years.

Dawn states in a letter she wrote to H. Edward Hanway, CEO of CIGNA, “Meanwhile, my symptoms worsen. Debilitating electric-shock-type pain racks my body and shoots through my head. I have sudden, painful seizures, sometimes knocking me to the ground. The seizure medications barely help, while their side effects ravage my body.”

Dawn has suffered from severe pain and the foreboding threat of death simply because these profit-driven insurance companies have decided that they don’t feel like forking over the cash to this critically ill patient. What a travesty!

To top it off, earlier this year CIGNA increased her monthly rate from $366.75 to $753.47, more than double the cost! Recently, Smith was also told that the co-pay on her anti-epileptic medicine was increasing from $10 every two-and-a-half months to $1,115. After receiving press attention, the cost was reduced back to where it was.

Dawn’s story is a harrowing representation of the everyday injustices caused by the greed of health insurance companies. Dawn states that during her fight she has met numerous others who have been denied care by their insurance companies and has begun a website (itcouldhappentoanyone.com) as a result.

And, it could happen to anyone, as Ian Pearl wrote at the end of his Huffington Post article.

Insurance companies regard everyone as potential dogs and trainwrecks. They won't hesitate to use similar tactics to avoid your claims if someone in your family suffers a catastrophic illness. Insurers don't like it when sick people live too long and cost too much.

I know firsthand that America's health care system has the capacity to provide incomparable, life-saving care. But I am living proof that insurance-company "death squads" meeting behind closed doors routinely make life-sustaining benefits vanish.

Without stricter enforcement of existing laws and the creation of a public health insurance option to keep private insurers honest, it's only a matter of time before you or someone you love will become the next victim.

Senator, Ian Pearl, Dawn Smith, Bill Caudle and the 57% to 65% of Americans who support a public option [9] don't want "free health care."

They just want to get the same quality of care when they get sick that, say, an uninsured gorilla [10] gets.

Instead of being treated like "dogs" by their insurance companies.