The U.S. Health Insurance System: It Shouldn’t be a Joke

Patient Experience by Elena K

The U.S. health insurance system often feels like something people joke about until those jokes lose their humor—especially when you’re stuck on hold with your insurance company after they deny authorization for a necessary surgery.

Navigating the Maze of Healthcare Jargon for My Orthopedic Claim

The health care system itself is a maze of jargon, even for people born and raised here. Terms like co-insurance, deductible, co-pay, out-of-pocket maximum, in-network, and out-of-network can quickly become overwhelming.

For the first five years I lived in the U.S., I didn’t even know what kind of insurance I had. Then, things started to change. Initially, it was just minor confusion about the mentioned definitions. But soon, I started grappling with bigger questions:

  • Why can’t you find out how much a procedure will cost up front?
  • What do the numbers on an Explanation of Benefits (EOB) even mean?
  • How can two people have the same procedure but pay different amounts for it?
  • Why is it so hard to get a straightforward answer about the cost of care?
  • How, after a 10-minute yearly physical exam, can a doctor determine your overall health with just a few questions?

(These remain more rhetorical than practical questions because it often seems like no one really knows the answers.)

A Torn Labrum, an Insurance Denial, and a Complicated Journey to Get Covered

In the summer of 2024, I was diagnosed with a torn labrum in my hip. I have good insurance with solid coverage, so I thought I was covered if any medical issues came up. My surgeon, Dr. Ramkumar, diagnosed the issue, proposed a treatment plan that involved arthroscopic surgery, and we scheduled the surgery for September.

Sounds simple enough—show up on the day of surgery, and the surgeon does the rest. But here’s where it gets complicated: larger procedures, like my proposed surgery, typically require pre-authorization from the insurance company. And of course, my insurance decided that this surgery wasn’t necessary.

The Insurance Denial: A Bureaucratic Nightmare

I’ll never forget the moment I called the insurance company in tears, trying to understand why they denied the coverage. The representative politely explained that there was no documentation showing I had completed six weeks of physical therapy, and that my alpha angle and CEA measurements didn’t meet their specific criteria.

What? I understood the physical therapy requirement, but the rest? What do those measurements even mean? What about quality of life? What about the physical and mental pain I was in? The insurance company didn’t seem to care, and it felt like they were just looking for reasons to avoid paying for the procedure—no matter what the doctor recommended.

When I finally got the official denial letter, the insurance company called the surgery medically unnecessary and listed a bunch of arbitrary requirements I would have to meet in to qualify for approval.

The Insurance Claim Authorization Process:

A Flawed System that is Emotionally Challenging for Patients, a Waste of the Surgeon’s Time and a Financial Burden for the Insured

Now what? Well, it goes something like this:

  • My surgeon determined I needed surgery based on my imaging, physical exam, and our discussions.
  • The practice submitted all the necessary paperwork to the insurance company.
  • The insurance company denied the request.
  • The surgeon then had to schedule a peer-to-peer review with the insurance company, hoping to convince them to approve the procedure.
  • If you are lucky, insurance authorizes the procedure.

So what do we end up with? The surgeon wastes time he could have spent helping other patients, I spend hours stressing out and crying over the fear that I might never get the surgery I needed, and the whole time, we’re all paying for the administrative bureaucracy that makes this whole process possible.

No wonder healthcare costs in the U.S. are so high—this is one of the reasons. Instead of approving the surgery right away, we waste time and energy, only to arrive at the same outcome.

A Painful Lesson in Healthcare Realities

Thankfully, through Dr. Ramkumar’s diligence, the surgery was eventually approved after the peer-to-peer review, and I got the treatment I needed. But even as I count myself lucky, I can’t help but think of how absurd the whole thing was. There was no real consideration for the pain I was going through, just a bunch of hoops to jump through.

Part of me understands that there should be checks and balances to prevent unnecessary surgeries, but when a patient is in pain, denying them the care they need feels inhumane. And I keep thinking of how my case was relatively simple—after all, it was an elective surgery. But what about people who depend on insurance for life-saving procedures? Their life is at stake and is in the hands of the health insurance companies.

Moving Toward a More Humane System

What I’ve learned through all this is that in the U.S., “healthcare” and “health insurance” are basically synonymous. You can pay a hefty premium each month for “good” insurance, only for the company to deny the care you need when it really matters.

I hope that, moving forward, patients, doctors, politicians, and insurance providers can work together to create a system that is more humane and affordable, where insurance companies are there to help their clients, not to make it harder for them to get the care they deserve.