If you were diagnosed with a serious illness that required a potentially life-changing surgery, would your health insurance company have your back?

That’s the question Bethany Kelly is afraid she already has an answer to. At age 26, she was recently diagnosed with a pineal cystic tumor in the center of her brain. The tumor has caused symptoms like memory loss, trouble saying the right words and even difficulty remembering her kids' names. 

“It’s exhausting,” she said. “You don't know how much energy it takes out of you to be in constant pain' all the time."

Bethany hasn’t been able to find a local surgeon willing to operate on her, and she says her insurance company won’t cover the only out-of-network doctors who would take her. She has appealed their decision at least three times and has been denied each time. 

“I have days where I just have to cry out to God and say, ‘God, take away the anger and take away the pain -- not only physically, but the emotional pain of going through something that's scary,” she said.    

If this happened to you, would you even know where to start? For most of us, the answer is no - and that's because most of us don't even pick our own health plan.

Scott Kowalski is the VP of marketing at WPS Health Solutions and teaches part-time at Madison College. He says there are a couple of things we can do, though, to make sure our plans are as comprehensive as possible. Oftentimes, employers will offer two or three options to choose from -- so, do your homework.

“We research weeks, months before we purchase a car, yet we don't do that kind of same research when we purchase health insurance,” he said. 

Also, do some digging on yourself. 

"What is your own history? How do you find yourself right now?" he suggests. "Take stock of your lifestyle -- so if you're smoking, if you're a heavy drinker, if you participate in risky behavior like hang gliding and auto racing those are things you want to  consider, too."

If you're already in a plan with no chance to change, that's no excuse. Kowalski says to be proactive, see what you're covered for, or find a timeline for when you can up your coverage.

"Be a student of the game," he said. “Understand what you’re buying, understand what your place is in the world at the time, and get help."

Meanwhile, Bethany's sense of self has changed because of her inability to get surgery. It’s hard to be a good mother and wife. She recently had to give up her beloved teaching job because of her symptoms.

"I feel like if you can change a situation, and you can change the quality of life for somebody and you're choosing not to, it's frustrating," she said. 

Bethany’s insurance company, Dean, told us its chief medical officer had expedited an independent review of her case to see if surgery is a medical necessity for her but said it couldn’t share any more specifics of Bethany’s case. Meanwhile, she has an appointment with a surgeon at UW Health. Still, should that doctor decide to take on her operation, it would be completely out-of-pocket since UW is not in her network. 

Author: Leah Linscheid 

Source:  Morgan Murphy Media.

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