Reasonable & Customary

I was a fairly intelligent guy. After all, I graduated high school. Yet I couldn’t understand the insurance explanation letter sitting before my eyes.

Was it written in a foreign language? Like English? No, not American, but English? Yes, that had to be it, because for the bloody life of me I couldn’t understand the bugger.

No. Not English—it was Insurance—Legalese! What did reasonable and customary mean? I mean, I was reasonable. I picked my doctor from referrals. Wasn’t that reasonable? And he picked his hospital…well, I can only assume it was a customary way to pick his hospital, but he was reasonable too. Yet I still didn’t understand what the explanation letter meant. It said that they only paid a portion of my medical bills, the portion that was “Reasonable and Customary.” Hell, I thought it was reasonable to pay the doctor as long as I lived. And I did. But then again, I thought it was customary for the insurance company to pay for my medical bills too. Was I wrong?
Obviously I was, since they seemed so opposed to paying the entire amount of any bill. Then I began to wonder. How was I, a patient, supposed to monitor my doctor’s spending during my operation? When I was knocked out? Was I supposed to only insist upon him using a general anesthesia so I could monitor his expenditures? I’d say, “Whoa! Stop –Now! That #9 thread is too expensive, use the #7. It’s just as good and costs half as much.”

And if the doctor insisted upon using a local anesthetic (because he’d had too many people saying “Whoa…”) was I supposed to hire a penitent advocate who would watch over every phase of my surgery to make sure my out of pockets expenses remained low. Even going so far as to negotiate the fee when necessary (“No, not the full brain surgery. Only the frontal lobotomy is covered and only in cases where mental illness is present.”) If my doctor should protest my advocate would say, “He can’t afford this surgery without the insurance. So I guess you should just let him die. If he’s lucky, maybe his life insurance will cover the overages. But don’t sew him up—just in case—because if my estimates are correct that last piece of $100 gauze maxed out his life and health insurance out.

Okay, so I figured it out, even though the explanation letter was in a foreign language. Reasonable and Customary meant whatever the insurance company wanted it to mean. Because I got what was reasonable and customary in Africa (the level of treatment my insurance paid for) even though I live in America.