Another Win for Health Insurers, a Big Loss for this Patient

Photograph Source: Marc Nozell – CC BY 2.0

I have suffered from Obsessive Compulsive Disorder for 27 years. In the Yale-Brown Obsessive Compulsive Scale Scale, I score in the “severe OCD” category. For 27 years I have seen one psychiatrist and therapist after another. I have been prescribed every kind of psychiatric medication imaginable, everything from Anafrinil to Zoloft. Nothing has worked.

My OCD has cost me jobs and threatened my marriage and contributed to my divorce.

When I heard about a relatively new therapy for treatment-resistant OCD patients called transmagnetic stimulation (TMS), I was excited. The treatment sounded promising. For the first time in decades there was hope that my days of suffering might soon be over. I am 57. Perhaps I could live my last ten or twenty years free from this terrible disorder.

I saw a doctor at a clinic that provides TMS and he readily agreed that my OCD would benefit from TMS for OCD. The only problem, TMS is not cheap. It is more than $6,000 for one round of treatment (as opposed to, say, $5 for a bottle of Prozac). And it doesn’t last forever. You often have to go back for more treatments, sometimes after months, sometimes years.

I have medical insurance, of course. Anthem Blue Cross Blue Shield, a for-profit corporation ranked 29th on the Fortune 500. My employer and I pay a lot for it. However, Anthem and its doctor denied our request for coverage. The reason: While TMS is covered for depression, it is not covered for OCD.

I was confused. The FDA approved TMS for OCD in August 2018. That is nearly three years prior to the time of my request. And yet Anthem Blue Cross Blue Shield is still not covering this treatment, even though it is one of the few things that seems to work for intractable cases of OCD like mine.

Why does it take so long for insurance companies to cover new treatments? I wish I could tell you. I asked Scott Golden, director of corporate communications at Anthem. He did not respond to my emails.

Basically, Anthem Blue Cross Blue Shield is telling me that they are happy to pay for treatments that don’t work (like Prozac, Zoloft, etc.), but will not pay for those that do work.

I was not surprised that my request for coverage was rejected. Until ObamaCare, health insurers were notorious for cancelling coverage for people with pre-existing conditions. While the law now bans that practice, Anthem has continued to reject coverage to sick and desperate policy holders. Most famously in May 2014, Anthem Blue Cross refused to pay for the hospitalization of a Sonoma County, Calif. man suffering stage four cancer, although he had paid Anthem more than $100,000 in premiums. After negative news coverage and a subsequent public outcry, guess what? Anthem paid for coverage.

Naturally, Anthem is one of the loudest voices objecting to health care reform.

After our request for coverage was rejected, we got ready to appeal, preparing a letter of medical necessity, requesting ancient medical records, submitting to more tests, anything that might help my case, knowing the appeal too would likely be rejected.

But there wasn’t much point to it. Like many companies, the organization I work for changes insurance providers almost as often as we change calendars, as medical costs continue to soar. I was notified recently that my employer is getting a new insurance provider. So, even if I went through the appeals process and won, it would be a waste of time. I will have to start the whole process over with a new health insurance company July 1, and they would doubtless reject coverage too.

Meanwhile, I was wondering whether my family–which already owes tens of thousands of dollars in medical bills thanks to the many (unrelated) eye surgeries I have had—can afford to go into even more debt to pay for TMS.

Not surprisingly, all of this began to take a toll on my physical and mental health.

Besides, OCD, I suffer from high blood pressure and anxiety and panic attacks. Eventually the constant stress and frustration of arguing with the health insurance company, the long hours on hold only to be cut off the moment I got a human voice, the constant wild goose chases, and the constant errors made by the health insurance company on documents and forms, proved too much for a person suffering multiple mental and physical health issues.

Ultimately, I decided the fights with the insurance company were not worth it. My anxiety and blood pressure were through the roof and my panic attacks were coming with increasing frequency. I feared I’d have a stroke or heart attack if the stress continued.

I told the doctors at the TMS clinic to forget it. No matter how bad the OCD, it wasn’t worth dying over.

I suppose this was some kind of victory for the shareholders of Anthem Blue Cross Blue Shield. They saved $6,000.

That’s what America’s health care system is all about after all. Keeping the shareholders happy and flush with cash.

There is a solution, of course. Medicare for All or some form of universal health care like every other developed nation on earth has. But, of course, that won’t happen here in the USA. Not in my lifetime. Americans love our insurance companies too much to allow them to become obsolete.

Don’t ask me why.

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