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Jumping through hoops

Jeffrey Goelz                                          Photo by Duncan Kendall

Even if your health insurance policy covers your motorcycle-related injuries, collecting your benefits may take extra time and effort.

Pennsylvania AMA member Jeffrey Goelz, a Motorcycle Safety Foundation certified RiderCoach who has been riding for 27 years, was involved in a crash with a car in September.

His 2002 Suzuki GSF Bandit 1200S was totaled.

“I was whisked away in an ambulance, in only my boots, gloves and helmet. Everything else was cut off me in the road,” Goelz says. “The treatment I received was based on the thought I had medical insurance on my motorcycle policy. I didn’t, as my previous insurance covered me for such things, and I didn’t read the fine print when we switched providers.”

At a follow-up visit with his primary-care physician, Goelz was told that his employer-provided health insurance plan would not cover his care.

He contacted the insurer and learned that his plan would cover much of the expense, but the health-care providers were required to verify coverage on each and every visit.

“This took days,” Goelz says. “Sometimes appointments had to be moved. But it needed to be done every time, and took far too long to approve.”

Goelz’s lawyer told him that, because Pennsylvania is a “no-fault” state, Goelz couldn’t collect reimbursement from the car-driver’s insurance company.

“I have yet to see a penny for pain and suffering,” he says. “My FSA (Flexible Spending Account) is almost empty because of the expenses I’ve had to incur because my health insurance would refuse me treatment without a ton of red tape.”

The ordeal affected more than just his physical health, Goelz says.

When he got on a training bike in October to teach a motorcycle-safety class, anxiety consumed him.

“Even on a little 250, in a parking lot, demo’ing exercises I could do in my sleep, my heart was pounding, and I would almost hyperventilate,” he says. “I remember one day not being able to do the figure 8 in the box, something I had great proficiency with.”

For about four months, Goelz didn’t get back onto a bike. He sold his other bikes.

By February, he was ready to try again.

“I put a deposit on a new (used) bike (a 2009 Suzuki GSF1250S),” Goelz says. “I would rather be anxious on two wheels and work through these issues than watch spring pass me by like a dog pressed against a window.”

The economics

Employers and insurers say they must exclude “risky behavior” from coverage to help contain the rising costs of health care and health-care coverage, several studies show.

But a study by the University of North Carolina’s Highway Safety Research Center shows that the average costs of motorcyclists’ injuries are actually slightly lower than the costs for other accident victims.

High-risk activities rarely enter the discussion about what drives U.S. health-care and insurance costs ever higher.

David Cutler, a health economist who has worked for President Obama on health care issues, told PBS NewsHour that three factors account for most of the high cost of U.S. health care:

• Administrative expenses, which account for about 25 percent of health-care costs;

• Doctors’ pay, drug costs and durable medical equipment prices are much higher here than in other countries; and

• Americans receive more care for the same illness or injuries than people elsewhere.

Meanwhile, a Harvard University study shows that unpaid medical expenses represent the biggest cause of bankruptcy in the United States, representing 62 percent of all personal bankruptcies.

The study also states that 78 percent of those filing for bankruptcy because of overwhelming medical expenses had some form of health insurance.

ACA brings no change

Kevin Lucia, a research professor and project director at the Center on Health Insurance Reforms at Georgetown University’s Health Policy Institute, says no federal standards affect individual or small-group policies and “there is a huge amount of flexibility for large companies” under the ACA and other laws.

His associate, David L. Cusano, says that each state must determine which exemptions are going to be allowed under policies issued within its borders.

The National Association of Insurance Commissioners agrees with that assessment.

None of the ACA rating provisions applies to self-insured employer plans, so there would be no effect on the use of motorcycle-rider status to determine employee contribution rates, according to an NAIC spokesperson.

And those plans are not subject to state insurance law, so the question of whether state laws address it is not relevant for them.

Fully insured group plans are subject to state laws, but not to the ACA rating requirements.

Most people in the United States are covered under self-funded employer plans, Lucia says.

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