Crawford began to read from his display, “Let's see ... $5,435 for emergency field treatment at the scene of the accident.” He chuckled to himself. “Talk about high liability insurance: those guys are covered to the gills.” He saw Gary's serious expression, cleared his throat and continued, “$675 for transportation to the emergency room, $3,125 for diagnostic CT scans and radiographs, $8,432 for blood work, IV medications, consults and emergency care. Oh, and $422 for the splints—each, that is. Not including your five days minimal hospitalization, you're already at $18,511. We estimate your daily hospital bill to be around $3,300. That will be a total expenditure by our company of $35,011. So you see, Mr. Carter. Chicago Casualty has been quite generous in providing you with quality emergency treatment and care up to this point."
“But you're supposed to make me well."
“Well, that's not exactly what the policy says, Mr. Carter. Did you read the policy?"
“Nobody reads those things,” argued Gary.
“We are only required to provide complete care in the event that recovery is imminent and full and the technology exists and is in common use. In other word, we can't do a head transplant until they become a codable procedure on the reimbursement form."
“But the doctor said they would be able to repair my legs."
“Furthermore, Mr. Carter, if a patient shows no signs of recovering, such as in a persistent vegetative state or requiring heroic measures to sustain life, we may elect to discontinue medical care."
“Again,” argued Gary, “I'm still here. Brain is fine. No machines keeping me alive..."
“I'm not finished, Mr. Carter,” interrupted the ferret. He cleared his throat and returned to the legalese he was reading. “If at any time, the cost to sustain a patient's condition or to repair damage exceeds the patient's intrinsic value, or treatment would not result in recovery of the patient to a value exceeding the costs, the insurer may decline paying further medical costs and attempt to recover costs as obtainable from the removal and distribution of body parts from the corpse."
Crawford smiled, satisfied with the explanation and obviously confident that his assessment was correct.
“To quote a famous Monty Python line,” answered Gary, “I'm not dead yet."
“For the purposes of your health insurance policy, Mr. Carter, you may as well be."
“You can't just kill me for parts."
“We wouldn't kill you. In fact it is better if the parts are harvested while the heart is still beating, for the major organs. Eyes and bones and cartilage and skin keep for quite some time."
“I must be dreaming,” concluded Gary.
“To be sure, usually when we declare a patient a total loss, they are already brain dead. But since the brain adds no intrinsic value to your corpse according to my tables, technically you are worth more as parts than if we fix you up."
“Not to me,” Gary retorted.
“Mr. Carter. The policy is clear."
“You can't get a doctor to do this, it's crazy."
“We have our own surgical technicians that do the harvesting."
“Don't I have to consent?"
“Not if you are a total loss. I admit the wording of the policy is not specific to your situation, but the way I interpret it we have a fiduciary responsibility to our shareholders and policyholders to cut our losses in your case and obtain as much salvage value as possible."
He tapped the screen again. “Now, considering your age and previous medical conditions, we can estimate values for certain organs and parts."
“I thought it was illegal to sell body parts,” muttered Gary, not realizing he was arguing in favor of his body having no value.
“Oh, we don't sell them per se. There is an allowable harvest, storage, distribution, and transportation fee that our subsidiary, which does all that stuff, is allowed to charge. The organs are of course free to whoever needs them, but we are entitled to some reimbursement for our trouble."
“Of course,” growled Gary,
“Heart and lungs come in at $2,568. Your previous history of smoking greatly reduces the value there."
“I quit ten years ago!"
“Still, the tables show a 70% reduction in value. Let's see ... liver, $3,211. That could be more if you were an abstainer, but we don't get many of those these days. Kidneys top out at $4,299 each, not a bad deal. Intestines and pancreas fetch about $6,849. Corneas at $355 each. Skin is too old for much use, but bone banks can make use of the long bones. However, since you have broken several of them, we can only get about $1,200 for the whole lot. Cartilage is likely all shot as well, but that wouldn't add more than a few hundred. That brings us up to $23,136. Subtracting from the $35,011, that leaves $11,875 in the loss column. Now if you had been a client for more than five years we could have credited you some unused premium contribution, but in your case I really have no choice."
“You're going to deny me medical care for $11,875? That's insane. I'll just put the balance on my credit card. Heck, a new car will cost me twice that."
Crawford placed his computer back in his briefcase. “That's not the way it works, Mr. Carter. If we did approve repairs, we're looking at almost two hundred thousand dollars in additional charges over the next year. I'm afraid we couldn't take the financial risk of continued insurance considering potential complications and your history of needing medical care."
“But this is the first time I've ever had to be in the hospital,” Gary argued.
“Exactly, Mr. Carter. You've been with us for less than three months. At this point, without surgery and rehabilitation, you're costing us an extrapolated yearly cost of $140,044 on a premium of $3,567. Numbers don't lie, Mr. Carter. I'll see you in five days,” he added as he left.
Gary slumped into the gurney. His wife was really going to let him have it now.
* * * *
“I told you so,” said Kate Carter with a touch of anger, but also relief that Gary was alive and appeared to be okay. Gary had been moved to a room on the third floor. The nurses were strangely subdued around him and he even felt a little neglected. Kate gently stroked his hair, avoiding the bandage on his forehead. “Are they going to have to operate?” she asked.
“There's a problem with the insurance,” said Gary, still trying to think how to explain the situation to her. He still couldn't fully comprehend it himself.
“I told David not to switch. He thought it would save the company a few thousand bucks. Don't worry, we'll get it straightened out."
“I don't know about that,” answered Gary.
“What do you mean?"
“They said that I was a total loss."
“You are a mess. Look at you: two broken legs, cuts and bruises. That car was a death trap. An accident waiting to happen."
“No, not a mess, a loss. They're writing me off. I'm too expensive."
“Your car?” she asked quizzically.
“No. It was the guy from the health insurance company. I'm a total loss. It would cost more to fix me than I'm worth, so they want to pull the plug and sell off my parts."
Kate's expression turned from confusion to amusement. “Very funny, Gary. Had me going for a second. Those pain medications aren't helping your sense of humor."
“It's not a joke,” said Gary. “I wish it was."
Kate looked more closely at her husband. “Gary?"
“What are we going to do?” he asked.
“We'll pay whatever the insurance doesn't cover. How much could it be?"
“It's not a matter of cost, Kate. Apparently they are entitled to withhold medical expenses and recoup the losses."
“That can't be legal,” realized Kate.
“It doesn't sound right to me either."
“Excuse me,” interrupted a voice from the door. “Mr. Carter?"
“That's me,” said Gary.
“I'm Dr. Wilson. I saw your chart at the station and since I'm the orthopedist on call, I thought I'd check in. Sorry I wasn't here sooner,
no one paged me we had an emergency.” The surgeon walked into the room as he flipped through pages in the chart. He was tall and young. His hair was black and wavy and his coat was immaculately white and pressed. A stethoscope hung around his neck. “Both legs, eh? Still, the radiologist's report is hopeful. We should be able to get you back up in six months or so."
“I thought...” started Gary.
Dr. Wilson looked up. His eyes widened to address his patient's concern.
“I thought the insurance had determined me a total loss,” answered Gary.
“What?” spat Wilson. “That's ridiculous, you're not even in a coma. Let me check your insurance page.” He flipped ahead, stopped, and squinted down at the page. Flipped back, then forward again. “I've never heard of this."
“Of what?” asked Kate.
“Well, on rare occasions, people's insurance coverage runs out or the doctors and insurance company agree that further treatment is pointless, but your husband here isn't in that position. It must be a mistake."
“That's what I thought, but the insurance guy went over the numbers. He seemed so analytical."
“Can't you just go ahead and fix him? Doesn't the hospital have the ability to help people without insurance?"
“Well, if you had no insurance at all, yes, we'd be obligated to provide care and repair the fractures, but you do have insurance and the insurance company has the option to cut their losses."
“That can't be right,” moaned Kate. “Can't we just cancel the insurance? It's not like we couldn't pay for it ourselves over time."
“The matter is out of my hands, I'm afraid,” pointed out the surgeon. “When it comes to financial matters, the hospital administrators don't like to get into battles with insurance."
“So they're just going to cut me up for parts?” asked Gary.
“Once they stop paying for care in five days, you're not going to feel much like living, especially as the bones start to heal back together in abnormal positions. Heck, you might get lucky and have a bone marrow embolism and it will be over like that."
“You're a doctor,” said Kate in shock. “How can you let this happen?"
“If there was a way to do this, I would,” said Dr. Wilson. “But my hands are tied. If I touch your husband I will not only be fired, but every insurance company in the country'd blacklist me. Worse yet, I can't even bill for this consultation.” He closed the file and walked out of the room.
“This is insane,” muttered Kate.
“That's what I've been saying,” agreed Gary.
Kate turned and watched Dr. Wilson return Gary's chart to the rack at the nurses’ station. After he walked down the hall to the elevators, she slipped over to the nurses’ station and lifted the folder, tucking it against her chest as she scurried back into the room. She started flipping through the pages until she found the section she was looking for.
“What are you doing?” asked Gary.
“All these insurance policies have loopholes and exceptions and twisted procedures and rules. Maybe there is a way to beat them at their own game.” She pointed at the record. “Here is the insurance page. You look this over. I'm going home to get our copy of the policy. We'll figure out something."
“You think we can beat this 33insurance company at their own game? Maybe we need to call the police or insurance board or something."
“If we can't find anything we'll have to, but maybe we can find something that will make them reclassify you from a total loss,” suggested Kate.
“Okay,” Gary said. “It beats being chopped up for parts."
* * * *
Gary and Kate spent the evening reading and rereading the policy. The language was so legalistic and twisted it took them several times through to adjust their thinking to match that of those who had written it. Kate was surprised to find that the policy only covered families for the first 2.2 kids. Their formula for determining care for 0.2 of a kid was pretty creative.
Gary found it useful to look at the policy as a computer program. No matter how well written, there had to be bugs. His scrutinizing finally paid off. In the case of the policy, the bug was a loophole—actually, several loopholes. Any by themselves were not a solution, but when he and Kate put them together, a plan began to formulate. They started work that night and soon had generated a couple of documents written on hospital stationery. When Kate was satisfied with their work, she headed home to type them up and make a quick stop at the bank before returning in the morning.
When she returned they had Dr. Wilson paged by a wary nurse. A few minutes later he was knocking at Gary's door.
“When can you do the surgery on my legs?” Gary asked.
“As I explained to you before, Mr. Carter, I can't get involved."
“Oh, but you can,” explained Kate. They explained their findings in the policy and Dr. Wilson found himself nodding in agreement.
“Very clever,” he concluded. “They have no choice when you put it like that. They worded their policy too well, it seems,” said Dr. Wilson. “I should be able to book an OR for this afternoon.” He picked up Gary's chart and made a few notations.
“Oh, and Dr. Wilson, be sure to use the very best stuff."
“Only the top-of-the-line for you, Mr. Carter,” answered the doctor.
* * * *
Later in the morning a nurse came in with some tablets for Gary to swallow. “They'll take the edge off for the anesthesia. They shouldn't knock you out, but you'll get a good buzz,” she warned.
“The buzzier the better,” said Gary.
A few minutes after that Crawford's confused face appeared at Gary's door. Gary was beginning to feel the effects of the medication. The pain in his legs was now just a constant ache.
“Mr. Carter, um, I'm afraid there's been some sort of misunderstanding,” he voice quavered with bewilderment.
“Mr. Crawford, come on in,” Gary invited. “I've actually been expecting you. I didn't think it would take long. You guys probably saw something pop up on my hospital bill and realized what was happening."
“Well, yes. The lorazepam tablets are typically given to preoperative patients, of whom you are not."
“Oh, but Mr. Crawford, I am a preoperative patient. In an hour I will be an operative patient, and later tonight I will be a post-operative patient. Chicago Casualty will be sparing no expense at fixing me up. Titanium alloy bone plates and screws, top-quality inpatient and outpatient physical therapy, the best pain medications, even a private room with cable and all the NFL games during my recovery. What's even better is that you'll owe me $12,900 at the end of the day. What a deal."
Crawford found a slight chuckle within himself. It came out like a stuttering turtle. “We don't even do that for patients who qualify for coverage, why would we do it for a ‘total loss?’”
Just then, Dr. Wilson entered the room. “Ah, Mr. Carter, I see you're nice and relaxed for surgery.” He flipped through Gary's chart, nodding with approval.
“There will be no surgery,” interjected Crawford. “I represent his insurance company and we have denied his claim. This patient is a total loss."
“Indeed he is,” noted Dr. Wilson. “Everything seems to be in order with regard to that,” he said thumbing to the appropriate section of the record. “Here it is, approved by a Mr. Bernard Crawford. That's you, I believe."
“Of course it is. Now cancel this man's surgery or I will be forced to call the hospital administrator and possibly deny any payment on this patient's bill."
“Can't do that,” said Dr. Wilson. “You can call the administrator, his extension is 1874. But I'm afraid he's signed off on this.” Wilson and the Carters had their turn at a laugh.
Crawford couldn't understand what was going on. He grabbed the chart from Wilson's hand and read over the insurance form. Everything was as it was the day before. Carter was a total loss. He was entitled to four more days of palliative care, then harvesting. It might seem cruel or unusual, but it was perfectly legal. The i
nsurance company was entitled to recover its losses where it could.
“Mr. Carter, you are entitled to four more days of care, then that's it. We are entitled to any and all salvageable body parts for distribution at our discretion. Now I don't know what you think you are pulling, but this must stop now. As it is I'm going to have a tough time with the lorazepam tablets going through. Since they weren't pre-authorized, the hospital may have to swallow those, so to speak."
“Mr. Crawford, you really must read the policy more carefully. I'm sure you have it memorized paragraph by paragraph, but perhaps you're too close to see certain ... subtleties. For once, the insurance company is going to get screwed and the best part is you did it to yourselves."
“What are you talking about?"
“It's your total loss provision, cleverly buried in a section on exclusions for special diets not related to metabolic or hormonal disorders prescribed by a clinical nutritionist under FDA livestock feeding guidelines. You guys must get a laugh when you write these things."
“The provision is clear,” commented Crawford.
“Exactly,” agreed Gary. “I'm not disputing the total loss. That's where your problem is."
“My problem?"
“Yes, the policy expects everyone to dispute the total loss. Who wouldn't? After all, we are talking about someone dying. Granted, most people covered under this provision are going to die anyway, but you never took into account specifically a patient who was still conscious."
“I still don't see what you are getting at."
“I waived my five days in the hospital,” said Gary.
“Waived them? Why would you do that?"
“I bet you guys thought it was pretty compassionate to include the five-day waiting period. Pay out a little for a few days, then reap a windfall with body harvesting. In fact, your little subsidiary that harvests parts and distributes them, for what are undeniably reasonable fees, doesn't even get notified until the day before harvest. Why should they? They have other things to do."
“So they harvest you early. I don't care if you give up the four days."
“Oh, you should. You see, since I won't be using my body for those four days, I'm entitled to compensation equal to but no greater than the daily expenses for unused days. That is, over and above my deductible of three hundred dollars."
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