Goldilocks and the HMOs

A Fractured Healthcare Tale

Once upon a time, Goldilocks lived in a country where medical care was not a right, it was a privilege. Goldilocks loved her husband and her son so much that she decided to give them the most precious gift in the whole wide world: healthcare coverage.

The problem is, you can't thrive unless they let you in.
The problem is, you can't thrive unless they let you in.

When she married Hubby she discovered he had been playing Russian Roulette with his health for years. She shuddered. She did research. She filled out an online application with Kaiser Permanente. She herself had Kaiser, and for the most part had had good luck with this giant HMO. Ok, there was that one time in 2003 when she slipped on a rock at Loon Lake and twisted her ankle and her PCF (primary care physician) declared it not broken without doing an x-ray and Goldilocks walked around on the ankle for a full week before going back and insisting on an x-ray, which showed a spiral fracture. Oops! Oh yes, and before that when her OB/GYN prescribed a medication for PMS, but she was on a similar medication already, and no one bothered to tell her she needed to taper off the first medicine before introducing the new medicine and she ended up in seizures and burst a blood vessel in her eye.

The important thing is that Goldilocks had health coverage. And Hubby did not. So she set out to sign Hubby up.

She read the Health Information questions -- all 8 pages of them -- aloud. Hubby supplied the answers. Many of them he could only guesstimate. It had literally been years since he'd seen a doctor, although he had gotten a sample of some blood pressure meds from a nurse practitioner about 6 months before.

When Kaiser (aka The Big Bad HMO) accepted Hubby Goldilocks was ecstatic.

But it soon became obvious they were only luring him into a false sense of medical security. Not unlike that cross-dressing wolf Goldi's friend Little Red Riding Hood kept running into in the forest.

Hubby immediately made an appointment to see his new doctor. He was so excited he told the doctor things he probably shouldn't have. Things about his medical background. Things about the aches and pains he was struggling with. Things that ultimately got used against him.

Height x Weight = Rejection.
Height x Weight = Rejection.

Hubby Was Too Big

A week or so later, Hubby received an official looking envelope from Big Bad HMO. His doctor, it seems, had blown the whistle on him. The doctor's notes indicated a plethora of "preexisting conditions" which Hubby had failed to disclose on his application. One of the most serious was that in guesstimating his weight (he and Goldilock owned no scale), Hubby was off by about 20 lbs. And those 20 lbs. were enough to tip him into an unacceptable BMI (Body Mass Index) range.

Big Bad HMO rescinded Hubby's membership. They went so far as to accuse him of FRAUD. Now, if there is anything you don't ever accuse Hubby of, it's dishonesty. From then on Hubby paid out of pocket for his healthcare.

If At First You Don't Succeed

Goldilocks was a quick study -- or at least she thought she was. She had learned her lesson with the acceptance cum rejection of Hubby's coverage. She was not going to let that happen to her again, no sir!

Now Goldi's offspring (Sonny ) had always been covered under his dad's plan. A very rich plan. A plan that Goldi did not want to deprive him of, especially now that his dad was dead.

Alas, the monthly premium to continue his benefits under COBRA was more (a LOT more) than poor Goldilocks could afford. Even though she was used to paying high Kaiser premiums for herself, $350+ a month for a healthy 17-year-old seemed outrageous.

Hoping for a loophole, any loophole, Goldilocks read the fine print of the letter from the COBRA administration. "Ah ha!" she exclaimed. "Here's something interesting!"

Notice of Premium Reduction

And Second Election Period

"If you have become eligible for COBRA continuation as the result of an involuntary termination of employment (as determined by the Employer) between September 1, 2008 and December 31, 2009, you may be eligible for a federally subsidized premium reduction. In addition, you may also be eligible for a second election period if your qualified event was associated with an involuntary termination of employment that occurred on or after September 1, 2008 and you did not have a COBRA election in effect on February 17, 2009 (i.e., you failed to elect during your original election period or you elected but lost COBRA coverage prior to February 17, 2009)."

Surely Sonny's father's death qualified as "involuntary termination of employment."  His dad would have continued being employed if he hadn't died. Except that by dying, he involuntarily terminated his employment. Likewise, Sonny would still have health benefits under his dad's plan if his dad hadn't died, his death thus triggering the involuntary termination of employment. Goldilocks thought out loud: "I think this scenario would fit any reasonable person's definition of involuntary termination, don't you?"

Actually, no, they didn't. It turned out to be part of a federal stimulus program to help the unemployed through the recession. The only way Sonny would qualify for the reduced COBRA premium would be if his dad had been laid off before he died.

Hearing this explanation from the COBRA administrator lady, Goldilocks didn't know if she was

a) Relieved that her ex-husband had not had to suffer unemployment on top of death, or

b) Angry that he had not been unemployed, so that she could afford the COBRA premiums for their son (or at least 35% of them).

Sonny's Needs Should be Small

Goldilocks decided it was worth a shot to see if Sonny qualified for an individual plan. If he did, she could bring his premium down under $200 a month. If he didn't... well, she'd worry about that later...

When she sat down to apply for health insurance coverage for the second time in recent years, Goldilocks decided to be uber-thorough. She would go with the full disclosure approach, leaving nothing out -- at least nothing that wasn't already in Sonny's medical file.

Since Sonny had been a Big Bad HMO member since shortly after birth, Goldilocks figured the medical review team could just go online and get any/all information they wanted to about Sonny's health history.

She also knew they were wont to toss the "F" word (fraud) around. And she didn't want it directed at her or at her poor son!

Sonny's Too Damaged

So once again, Goldilocks diligently filled out the 8-page questionnaire. She filled in names of Sonny's doctors. She didn't hold anything back. If a piece of information might be in his chart, she wanted to make sure she put it on the application.

Five days later Goldilocks logged on and saw she had a message from Kaiser. She eagerly went to the page, anticipating good news. What she got instead pushed her blood pressure to the boiling point.

Their denial of coverage letter spat back in her face the very details she had so carefuly disclosed. Big Bad HMO was unable to offer Sonny coverage due to the following:

1. He's sought treatment in a medical professional's office within the past 12 months.

2. His history of acne.

3. His history of situational stress, anxiety or depression.

I am not making this up.

Goldilocks was furious. Was it her fault their stupid  check "yes" or "no" format did not allow for clarification or explanation? Yes, Sonny had suffered "situational stress, anxiety or depression." In point of fact, though, he had never, ever been diagnosed with depression. But he definitely suffered stress and anxiety. What 17-year-old with a chronically ill -- now deceased -- father wouldn't?

As for seeking medical treatment in a doctor's office within the past 12 months, whatever happened to "wellness visits" or "annual checkups" anyway? If Sonny had sought treatment 12 times in 12 months, sure. That might be considered excessive consumption of resources. But one visit to the pediatrician (required to sign up for sports each Fall) and they jump to conclusions that he's gonna bankrupt the whole system. Geesh.

And last but not least, acne. Sonny does not have a "history" of acne. He is a normal 17-year-old with a few random breakouts. He didn't even see a dermatologist. His PCF placated him (truly, his skin is not bad at all) with some prescription topical creams. Goldilocks only checked "acne" because she didn't want the medical reviewers peeking into Sonny's prescription history and finding -- God forbid -- undisclosed zit cream.

Don't mess with Goldilocks
Don't mess with Goldilocks

And Goldi, She's Juuussssstttt Pissed

In the original story, Goldilocks eventually got it just right. She found the perfect porridge, chair and bed for her. And she even made friends with the 3 bears. Aw. Isn't that nice?

But our story, remember, is fractured. There is no happily ever after when it come to negotiating with the Big Bad HMO. Sure, Goldi still has health coverage, but she pays a pretty premium for it, let me tell you. And at least Sonny is still eligible for COBRA. All Goldi has to do is find an extra $350 in her budget every month to pay for it.

But back to the story.

Being a true heroine, Goldilocks took on the challenge.

Did she suffer from situational stress and anxiety over it? You bet.

Did she pray every day for a new, perhaps statewide or even national system that could never deny coverage to anyone, or any reason? Absolutely.

But shhhh... please don't tell the Big Bad HMO ... or they'll probably find a reason to drop her as a member, too.

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Comments 23 comments

Shalini Kagal profile image

Shalini Kagal 7 years ago from India

Is there no alternative? Does she just have to grin and bear them, then? Great take, wonderfully told MM :)


bgpappa profile image

bgpappa 7 years ago from Sacramento, California

Irony that HMO's would accuse anyone of fraud when they engaged in deceitful behavior all the time. Sorry about what happened to you. This is a tale told around the Country every day but still sucks when it happens to you.


Laughing Mom profile image

Laughing Mom 7 years ago

You couldn't have written this one any better, MM!! Applying for healthcare is exactly like applying for a loan: Convince us you don't need it, and we'll give it to you.

COBRA is...well, ridiculous! But then so are most HMOs. We switched to a PPO this year, which is a little better in terms of not having to have referrals or being required to see multiple doctors for the same ailment. But actually GETTING the insurance is the big problem. Then of course trying to pay for it.

The fact that you're left dealing with these problems because, in the government's eyes, your son's father had the nerve to go and die while still holding down a job is.....I can't even think of a word.

I'm glad you finally found the right porridge and chair, but I'm really sorry about all the hassle.


Mighty Mom profile image

Mighty Mom 7 years ago from Where Left is Right, CA Author

Ha ha, Shalini. Grin and "bear" them! Is that a pun? Seriously, if one carrier denied coverage it's a sure bet others will, also. There is something called a "conversion plan" that guarantees coverage. Goldilocks is checking those benefits and costs against COBRA. And also working extra hard so she makes more money which she will probably end up spending on COBRA.

Thanks for visiting! MM


Mighty Mom profile image

Mighty Mom 7 years ago from Where Left is Right, CA Author

Bgpappa and Laughing Mom, Of course there is an "easy" alternative to all of this, which is for Goldilocks to go back to working for an employer that pays her health benefits so she can cover Sonny as well. The reality here in the capital of the great state of Kalifornia is jobs are tight, tight, tight. When they're cutting sheriffs and state workers and city workers -- you know things are tough. No, methinks we'll just look into any SS benefits that Sonny might be eligible for and use them to cover his health care. Or at least the prescription zit cream:-). Gotta get to bed. Thanks for stopping by. Hope all's well! Best, MM


raiderfan profile image

raiderfan 7 years ago from Arizona

It should be a right not a priviledge. I saw half of the movie sicko and got too pissed to watch the rest. I had to drop my insurance because of the recession and now I can only hope no trees fall on anyone.


maggs224 profile image

maggs224 7 years ago from Sunny Spain

I cannot believe that a country that leads the world in so many ways does not provide basic health care for its citizens based on need rather than ability to pay or health insurance cover.

Like most insurances the world over they are great until you need to claim then out come all the reasons why in this particular case you are not covered.

Great hub had me reading right up to the end, but also getting a little angry that the health care system you have seems to be run for the benefit of the HMOs not the people who need to use it.


Hawkesdream profile image

Hawkesdream 7 years ago from Cornwall

All I can say is, thank goodness for our National Health system , where medical treatment is free to all.

The only time that we have to pay, is if the system isn't fast enough, and we choose to go private.


ralwus 7 years ago

Goldilocks needs to cover her marshmallows better! If you get my drift?


dineane profile image

dineane 7 years ago from North Carolina

sad story, MM, but well told. My frustration, too, just keeps growing and growing. Good luck with Sonny's health care.


dianacharles profile image

dianacharles 7 years ago from India

I think this is becoming the trend around the world. Sad!


Mighty Mom profile image

Mighty Mom 7 years ago from Where Left is Right, CA Author

Raiderfan -- Sorry but not the least bit surprised you had to do that. I hope there are not little Raiderfannettes going uncovered as well.

Maggs224 -- Basic incompatibility between our capitalistic economy which makes healthcare a profit-driven industry and an attitude that healthcare should be the right of all citizens.

Hawkesdream -- Your national healthcare system cannot possibly be working. Don't you know that the very concept is heresy:-)?!!

Ralwus -- Aha. So you got it! Goldilocks is feeling a little exposed. Not only does she do her own breast exam, she now has to do her own mammograms...

Badco -- I know, hunh? Now Goldilocks is wishing she'd done the Hub Challenge so she could have a few more Hub dollars in her pocket: -- well, not in her pocket for long,

Dineane -- Thank you. I know we are not alone. Our situation is mild compared to some. Prisoners get healthcare but honest citizens don't. What kind of values does this country have anyway???


LondonGirl profile image

LondonGirl 7 years ago from London

$350 a month?! Bloody hell.


RedElf profile image

RedElf 7 years ago from Canada

Wow - great info. I had no idea...and a delightful way of presenting - thanks


Mighty Mom profile image

Mighty Mom 7 years ago from Where Left is Right, CA Author

Fraid so, London Girl. Don't get me started. If Costa Rica can have nationalized healthcare, why can't we?

RedElf. Believe it or not, I did not get the idea for this hub from Michael Moore. Unfortunately, our story is not at all unique. And we are on the fortunate side of the equation -- I still have options to get Sonny healthcare. Thanks for visiting!


Frieda Babbley profile image

Frieda Babbley 7 years ago from Saint Louis, MO

I'm just going to say be glad you don't have a six person family. Sucks.


Mighty Mom profile image

Mighty Mom 7 years ago from Where Left is Right, CA Author

Frieda. Tell me about it! I certainly hope that is not your situation, dear !!! If I had a choice between $ and guaranteed health care coverage I would take the latter. It is worth more than gold.


pgrundy 7 years ago

Oh MM, I could go on for hours about this... and I have. But I won't here. I promise.

Suffice it to say I gave up when I used my subsidized $120/month coverage through work (for me only, just me) for the first time in two years--when I suffered what looked like heart attack at my desk-- and I still ended up $5,000 in debt after the insurance paid out $15,000 (for a day and a half). I was released with no treatment plan (and not much in the way of test explanations either) into the care of my personal physician who prescribed a narcotic (for stress!) even though it's right on my chart I can't go there... plus he never even looked at my tests much less explained what did happen. Plus, why would you ever ever prescribe a highly addictive drug for stress? If it even was stress?

Well, after that I gave up. I threw out the prescription, and now I have no health insurance and no job. I feel weirdly safer, even though I suppose I'm not. I mean, the care sucks here. It sucks to a degree that has gotten scary. Great hub.


Mighty Mom profile image

Mighty Mom 7 years ago from Where Left is Right, CA Author

Hello dear friend, PGrundy. Yes, I know you have written on this topic eloquently and often. One of many favorite rants. Anyone who is not up in arms about the state of healthcare in this country is seriously in denial.

Your story, though devestating, is all too common. And I've got friends ( you probably do, too) for whom the debt number was $50K not $5K.

I think in some strange way you probably ARE safer now. I don't know what your financial situation is, but I do know that people receive care every day and do not pay one cent for it. If (God forbid) you or your man get sick, why should you get it for free? It's not like they can deny it to you. I really believe the entire system is resting on the backs of us in the middle. If you're rich, you're set. If you're poor (or in prison or recently out of prison or on SSI) you're set. But if you are struggling to pay your bills every month and are underinsured -- you're screwed.

Thanks for visiting. I'm thinking my next rant hub might be about health care horror stories -- not the financial side, the care side...


pgrundy 7 years ago

I'll be there to read it if you write it. I think you'll get a lot of folks contributing their own horror story in comments.

I agree with you--it's all on the backs of the people in the middle. The sorry truth is we already have single payer health care--and middle class people are single payers and HMOs get to keep all the profit. That's messed up.

Mostly though, I meant I feel safer being out of the system altogether. Financially I'm not safe at all. None of us are at the moment. What a mess.


Mighty Mom profile image

Mighty Mom 7 years ago from Where Left is Right, CA Author

I know. It's scary to be middle aged and so financially un-set. How did this happen?

I'm def going to write that hub. May have to skew it so it isn't USA-centric. Our Hubber friends around the world just look at us when we talk about this crap and scratch their heads. How can it be? I'll give it more thought -- I certainly have enough examples to fill a hub, that's for sure!


Christoph Reilly profile image

Christoph Reilly 7 years ago from St. Louis

I don't want to get started on this! Gawd, it makes me angry. Let me just say that I loved your style and technique in telling the true-life horror story of modern medical care. Thank you for your entertaining skill!


Mighty Mom profile image

Mighty Mom 7 years ago from Where Left is Right, CA Author

Aw, CR. Your sweet comment almost makes up for the rejections. Almost:-). But thanks. It is nice to be appreciated! Happy Friday, my friend. MM

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