A Pennsylvania Man with double insurance still owes nearly $150,000 in medical bills after bike crash
CBS This Morning” is inspecting sudden medical prices as a part of our persevering with “Invoice of the Month” sequence, in partnership with Kaiser Well being Information and NPR.
We are able to all study some classes about well being care from a former skilled athlete who had a critical accident and ended up in intensive care. Bicycle owner Phil Gaimon was left on the hook for about $150,000 in medical payments — regardless that he had each major and secondary medical insurance.
In 2019, Gaimon was racing in an Olympic qualifying race when he collided with one other bike owner. He was thrown from his bike at about 40 miles an hour, breaking seven bones.
Gaimon was rushed unconscious to a close-by ER, at Lehigh Valley Hospital in Allentown, Pennsylvania.
“So after I awoke, it was excruciating ache,” Gaimon mentioned. “I might damaged all of the ribs on my proper aspect, my collarbone, and … my scapula, my shoulder blade.”
Gaimon acquired collarbone surgical procedure at Lehigh Valley Hospital and a second surgical procedure on his shoulder bone on the Hospital for Particular Surgical procedure in New York.
“Each of the surgical procedures have been fully essential,” Gaimon mentioned. “I used to be simply in super ache throughout.”
He made a rapid restoration at house, however then the payments got here.
They totaled over $200,000 from each hospitals. His two insurances paid a complete of solely $52,000 — leaving him on the hook for about $150,000.
He realized Lehigh Valley Hospital was out of community. And his shoulder surgical procedure was labeled as an “elective” process as an alternative of an “emergency” — which may have saved him cash.
“They hit you with the payments while you’re actually least able to dealing with something,” Gaimon mentioned. “I get a stack of payments each month. I get assortment notices daily.”
Dr. Elizabeth Rosenthal, editor-in-chief of Kaiser Well being Information, instructed “CBS This Morning” concerning the scenario. “Hospital billing is crammed with landmines. And Phil hit three of them — out-of-network hospitals, excessive prices, and this is the biggy in his case — insurance coverage from one state typically does not work very nicely in one other.”
Rosenthal mentioned Gaimon obtained hit with one thing referred to as balance-billing, a sort of shock invoice.
“You go to a hospital that is out of community and, in keeping with all of the shock billing legal guidelines that many states have, you are solely imagined to be charged in an emergency what you’ll have been charged at an in-network hospital,” Rosenthal mentioned. “So Phil’s insurer, which was California-based, paid what it thought of an affordable fee … Each hospitals wished much more, and so they balance-billed Phil for the distinction. If he’d been in California, which has surprise-billing regulation, that will have been unlawful. However as a result of he was in Pennsylvania and New York and insurance coverage is state-regulated, they might do it.”
“So there are some issues you are able to do,” Rosenthal mentioned. “In fact, Phil was unconscious, so, , you are not in a spot to be a savvy well being care client. However if you’re nonetheless awake, you’ll be able to ask to go to a hospital that is in-network once they ask you to signal these varieties that say I am going to pay for something my insurance coverage does not cowl, you’ll be able to add in so long as it is in my community. And you’ve got a selection if an ambulance comes to choose you up and you do not suppose you want an ambulance, you’ll be able to say I am not getting in.”
Gaimon has spent months calling and writing letters to his major insurance coverage, Well being Internet, to steer them to cowl extra of the payments, however he has been unsuccessful.
Well being Internet mentioned that they’re dedicated to offering high-quality care with a good selection of in-network suppliers and that members ought to contact them for help.
“This might occur to anyone at any time — the place you’ll be able to simply get up in a hospital after which later discover out you owe them $150,000,” Gaimon mentioned. “I want I knew that getting medical insurance was nonetheless, primarily, a bet.”
Lehigh Valley Well being Community instructed Kaiser Well being Information that they don’t have any document of Gaimon making an attempt to contact them about monetary help and that they’d be joyful to debate a mutual decision of his excellent stability.
The Hospital for Particular Surgical procedure mentioned they reached out to Gaimon to assist resolve the dispute concerning the surgical procedure classification and can proceed to advocate on his behalf.