How an insured professional athlete ended up with $ 250,000 in medical debt

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In the United States, going bankrupt because of medical bills and debt does not only happen to the uninsured hapless, but also to insured people.

Although Medicare plans have a “maximum outlay” – the highest amount you would have to pay for medical services in any given year – this does not guarantee that this number will provide a safety net. .

That’s what professional cyclist Phil Gaimon discovered after a serious accident in Pennsylvania last June that broke his collarbone, scapula and right ribs. The invoices amounted to $ 250,000.

“I have good insurance,” Gaimon told Yahoo Finance. “I pay a lot of money for it. I just didn’t get a good explanation for all of this.

Gaimon pays $ 500 per month for a plan with a $ 10,000 deductible and battles bills.

Cycling: 5th Grand Prix Cycliste de Québec Phillip GAIMON (USA) / Québec – Québec (199.1Km) / Grand Prix de Québec / (c) Tim De Waele (Photo by Tim de Waele / Corbis via Getty Images)

This type of medical debt is not uncommon. The Kaiser Family Foundation, a healthcare think tank, has reported that insurance can be incomplete and the complexity of the system often leaves people seeking treatment in financial difficulty. In a survey, KFF found that 11% of consumers with medical bill issues filed for bankruptcy and cited medical bills as at least partial contributors. Another report found that medical problems contributed to 66.5% of all bankruptcies. (Currently, there is legislation dealing with surprise billing issues.)

Gaimon was taken by ambulance to the nearest hospital after his accident. Unfortunately, it turned out to be an off-grid hospital. Gaimon told Yahoo Finance he believes everything will be fine, as the nature of the emergency could be considered a mitigating circumstance. Its insurer, Health Net, has an appeal process for situations like this.

Gaimon thought the no-other option of the situation would solve the problems, and felt it was enough to post on Instagram soon after that people should donate to No Kid Hungry, a charity for the. food insecure for children, rather than a GoFundMe for its bills.

“I said, ‘Hey I broke down, what would you give my GoFundMe if I didn’t have health insurance? “Take that money and give it to this instead,” Gaimon said. “We raised around $ 40,000 in 48 hours. “

The $ 103,000 raised over the next few months would have significantly reduced his medical bills, but Gaimon has no regrets. “Someone needs more help than me,” he said.

It’s hard to compare when you’re in physical pain

Things might have been easier if Gaimon had been able to direct the ambulance to a network hospital. But an ambulance is not a taxi, it is a vehicle designed to get a patient to health care providers as quickly as possible.

Also consider that Gaimon, as he put it, was in “various states of consciousness” following his accident – barely able to verify which hospitals are in his insurer’s network.

Gaimon may be able to win the appeal process with his insurer for the off-grid hospital. But this is only the beginning of his insurance problems.

The cyclist’s scapula fracture was complex enough to require a special surgeon, and Gaimon said the hospital was unable to find someone capable.

“I was lying in the hospital for three days administering morphine,” Gaimon said. Several times a potential surgeon would come to examine him to tell him that he was not up to the task.

After several cycles of fasting before surgery only to be told surgeons couldn’t operate, Gaimon took matters into his own hands. Eventually, he found a surgeon in New York to do it, and even though he was also off-grid, he figured that the fact that there was apparently no other alternative would mean his insurer would cover the surgery.

Six months later, Gaimon finds out that’s not the case and fights the charges. He hired a lawyer to help him, which has had mixed results with the system so far.

“Nobody talks about pricing until it’s over – that’s the other horrible flaw,” he said.

Gaimon said he’s insensitive to things at this point, though he’s not sure what’s going to happen.

“Ultimately, I’m going to have to negotiate with this hospital, or health insurance will choose to cover,” Gaimon said. “Or they will have to sue me and I will go bankrupt – the traditional way of doing medical business.”

Gaimon’s sarcasm aside, exorbitant healthcare costs are a central issue in the current presidential election and a frequent talking point for Democratic candidates. In this week’s Democratic debate, Senator Bernie Sanders highlighted the problem. “You have 500,000 people who go bankrupt because they can’t pay their medical bills,” Sanders said. “We spend twice as much per capita on health care as people in any other country.

This whole ordeal has shown Gaimon just how fragile the health care system is.

“The idea that you could have a car accident and wake up in a hospital and owe $ 100,000 – and it could happen to anyone – is a ridiculously scary thing,” he said. “I wasn’t making any decisions, I was taking medication, and I was in pain in the fetal position. Every decision was made for a living. And then you emerge and you are financially ruined.

Ethan Wolff Mann is a writer at Yahoo Finance who focuses on consumer issues, personal finance, retail, airlines, and more. Follow him on twitter @ewolffmann.

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