Undecipherable health insurance documents

I was very happy when I finally received the document from my health insurance company explaining my medical coverage. Now I could finally see exactly what medical benefits are covered. Or maybe not. I decided to review it so I would know what is covered and what isn’t. I didn’t get very far. The document is extremely unreadable and hard to understand. I gave up and decided that I will read relevant sections carefully when and if I need them. Why can’t these documents be written in plain English so that average people can read and understand them? What about people who read at low grade levels? These documents seem like they are written by lawyers with the express purpose of confusing the rest of us.

Here is an example from the plan document’s “Exclusions and Limitations” section. This is exclusion number 2 out of 75: “Benefits may be reduced; or denied if subject to the Managed Benefits Managed Care Guidelines. Any reduced or denied benefits paid by the Member do not count toward any applicable Cost Share Maximums shown in the Schedule of Benefits.” I think I figured out what it means but I had to read it several times.

A recent New York Times op-ed piece discusses this issue and gives the example of a man whose chemotherapy was denied by his insurance company. He couldn’t understand his insurance policy and why he was denied. When the Rhode Island Health Insurance Commissioner’s Office called the insurance company on his behalf, they were told that the claim was denied because they were still trying to figure out if the medical services were covered. They didn’t understand the policy either.

Starting next year, Rhode Island will require that all insurance policies are written at an eighth-grade level. The US House of Representative’s health reform bill has a proposal that some parts of insurance policies should be written in “plain language.” There is other proposed legislation at the federal level that would require “uniform and simplified coverage information.” Insurance policies must be understandable to be useful.
Jen Ramirez