Who’s got you covered? Maybe not your health insurance
Healthcare. They all had health insurance. But when they really needed it, they found only red tape. These are their stories.
Timothy McCarty, 64, knows he hasn’t taken the best care of himself. He has been smoking since he was 15 – everyone did back then, when there was a smoking lounge at his high school in Sussex, NJ. He worked construction and more or less avoided doctors until he was 45, when his habit started to catch up with him, he said.
Now retired, disabled and on social security, McCarty lives alone in a ranch house in Milford, PA where he watches a lot of news and war documentaries. A dozen or so pill bottles – for diabetes and high blood pressure – line the kitchen counter, and cigarette butts half-fill a can on the kitchen table.
He is planning to quit smoking, but was too stressed right then. The day we met was the day before the surgery he was having for the bladder cancer he learned he had over the summer. At this point, the pain and the need to “go to the bathroom every five minutes” keeps him from going out much, other than to doctor appointments. A good night’s sleep is a distant memory. He’s been spending his nights dozing in his recliner in front of the TV, catching an hour of sleep here and there.
But what’s really weighing on him is fear of what the surgeon will find. “I just hope he doesn’t go in there and find out it spread and stuff. That stuff is nasty. It killed a lot of people in my family.”
To add to the stress, a week earlier McCarty had gotten a call from the hospital: his insurance, which he’d been sold over the phone a couple months earlier, would not cover the surgery.
McCarty lives in Pennsylvania, while Garnet Health Medical Center, where he was scheduled to have his surgery, is across the state line in Middletown, NY. Unbeknownst to McCarty, it turned out his insurance, a managed Medicare plan administered by Aetna, did not cover out-of-state surgeries.
McCarty lives off a social security check. There was no way he could afford the surgery himself.
“The hospital is stuck. I’m stuck,” said his surgeon, urologist Dr. Michael Hoffman, when he heard that the surgery wouldn’t be covered, days before it was supposed to take place. “This patient had no idea that his managed Medicare plan did not cover surgeries out of the state. They called to sell him. The plan made no mention of these arbitrary restrictions.”
How did McCarty end up with a plan so wrong for him? (Long story, see sidebar.) All McCarty knows is that someone called him up late last year and told him his plan was being discontinued at the end of 2025, and offered him another plan with lower co-pays. McCarty specifically asked if he could keep seeing his doctor in Port Jervis, NY and was told yes, he said. The telemarketer never mentioned the prohibition on out-of-state surgery, he said.
“I’m not really too savvy with all this stuff, you know. They can get over on me really easy,” McCarty said.
A potential death sentence
Dr. Hoffman of Middletown Medical, who’s been practicing since 2008, called the denial “a shocking kind of a scenario to encounter” with somebody eligible for Medicare.
Traditional government-managed Medicare “doesn’t deny things” for the most part, Hoffman explained, though there is cost-sharing with the patient and a lot of paperwork involved on the part of the doctor.
McCarty’s case illustrates a nationwide trend, in which insurance companies – still some of the most profitable enterprises in the world notwithstanding notable headwinds over the past year – are increasingly finding ways not to pay claims. Denial rates jumped 16 percent from 2018 to 2024, according to The American Journal of Managed Care.
CVS Health, which acquired Aetna in 2018, is the world’s second-largest healthcare company with revenue over $400 billion, behind only United HealthCare Group. The CEOs of the six major national health plans earned a collective $159.4 million in 2024.
Meanwhile, older and disabled people like McCarty are increasingly suffering the fallout of rejected insurance claims as healthcare companies have begun scaling back their Medicare Advantage offerings drastically in 2026.
McCarty’s first thought upon learning that his surgery wasn’t going to be covered was that he’d have to find another doctor in Pennsylvania. “How long that would take?,” he wondered. “And I need that surgery six months ago.”
From intake to surgery, finding another medical team would have meant a delay of multiple months, estimated Hoffman. In McCarty’s case, the cancer was already “muscle-invasive,” said Hoffman, and further delay to “prove and remove” it could have amounted to a death sentence. “It’s the difference between having your treatment be initiated when the cancer is still curable, versus then now having to entertain the prospect of managing your cancer knowing that it’s not curable,” said Hoffman.
But an old friend of McCarty’s offered to pay for the surgery, and around the same time, Garnet Health Medical Center called to tell him to come apply for charity care – which he was granted.
“Either way I was having it,” said McCarty. “You shouldn’t have to get charity care though, when you got insurance, you know?”
In the end, the hospital’s charity care fund covered the hospital’s portion of the surgery, while McCarty’s friend paid for the doctor (about $1,000) and anesthesiologist (the bill had yet to arrive).
After the surgery, I checked in on McCarty. He sounded tired. They hadn’t gotten all the cancer, he said. His bladder would probably have to come out, and he’d have to go through chemo. The good news was that a local insurance agent who had been contacted by Dr. Hoffman was able to get McCarty on an appropriate Aetna plan beginning February 1. It had higher co-pays and deductibles than McCarty’s discontinued plan had, and it wouldn’t retroactively cover his surgery, but it would cover his care in New York going forward, like the PET scan he would have the following week.
The PET scan would be a major fork in the road for McCarty. He wanted to live, and had already cut his cigarette habit by half days after his surgery. But “if it spread, I’m gonna do nothing. Not going to suffer from chemo the last whatever I have left,” he said.
In the wake of this reporter’s inquiry, a representative from Aetna had been calling McCarty -- four times in a single day, he said. They were attempting to gather information, to “help us investigate whether any marketing mis-representation occurred,” as a spokesman explained to this reporter. But for McCarty it was too little, too late. He told the Aetna representative he had nothing more to say to them and hung up.
“The guy who killed that CEO in the city, you kind of know why he did it. Not that I think it’s right to do. They just rob you,” said McCarty, referring to the 2024 murder of UnitedHealthcare CEO Brian Thompson for which suspect Luigi Mangioni is now on trial.
“They don’t give a shit if you live or die as long as they get their money,” he said with a shrug. “And actually somebody really sick, I think they’d rather you die so you don’t have to cost ‘em all that money.”
His treatment suddenly labeled ‘experimental,’ a life is upended
Jamie Rich, 53, of Lake Hopatcong, NJ, discovered he had a rare, life-threatening autoimmune disease six years ago, when he started coughing up blood in the middle of the Covid pandemic. The father of three went into the hospital for what he thought would be a weekend, and ended up being hospitalized for three-and-a-half months. A team of doctors at Morristown Medical Center finally identified the condition causing him to hemorrhage from his lungs and kidneys – with thousands more microclots in his brain and legs – as Catastrophic Antiphospholipid Syndrome (CAPS). Because of Covid protocol, his wife was the only one allowed to visit him in the hospital.
“They just kept throwing all these different meds at me,” said Rich. One of the drugs, an intravenous infusion called Ultomiris, worked. For the last five years Rich, a wealth adviser, has had an infusion every eight weeks.
“I’ve been so conscious of my health. I’m only 53 years old. I don’t want to feel like an old man anytime soon. I eat well, I work out regularly, and I stay on top of my medications.
“After an infusion I sleep for about a day but then I go right back to my lifestyle, and I don’t notice any difference in my health. I know that I don’t feel bad. I just don’t ever want to feel the way I felt six years ago,” he said.
The infusions were covered by Rich’s employer-sponsored health insurance, UnitedHealthcare. But when his company switched to Aetna, they denied his treatment, calling it “experimental” – a label that varies from one insurance carrier to another. When we spoke in February, Rich was nearly a month overdue for an infusion, and his normally understated doctor was suggesting that “if this goes sideway, you need to sue somebody.”
Ultomiris is mindbogglingly expensive. “Every time I sit in the chair at the infusion center, $330,000 is billed. Then they negotiate back and forth, back and forth, and they square up around $70,000,” he said. “It’s a little tiny bag. You couldn’t even make a meal out of it if was something to be consumed.”
Rich had to interrupt our interview for a call with his hematology team, which was scrambling to find yet another Aetna representative willing to submit another claim. Rich had just received a letter from the insurance company, which he was going to ignore, “that said this is your last and final denial. There will be no more reviews of your coverage,” he said.
They had not suggested an alternate treatment for his condition. “Nothing, just deny, deny, deny,” he said.
Without the infusion, “I’m starting to get run down a lot quicker,” said Rich. “I don’t know if this is just me being psychosomatic about things because I’m starting to get upset and depressed about the fact that there’s a possibility of me not having this going forward.”
After a motorcycle accident, ‘it’s just a delay after a delay after a delay’
Robert Annunziato of Greenwood Lake, NY, flipped off his motorcycle in his driveway in 2023 and “pretty much bent his knee backwards,” recalls his wife, Jessica Annunziato. He went to the emergency room, where they let him go with a soft cast and instructions to follow up with an orthopedist, who said – to no one’s surprise – that he needed an MRI.
Both Robert and Jessica were self-employed, and paid about $1,000 a month for their family’s health insurance through the Affordable Care Act’s health insurance marketplace. So it came as a shock that “we just kept getting denied,” said Jessica.
The insurance company, Fidelis, wanted Robert to try physical therapy before going for an MRI, she said. But Robert couldn’t so much as lift his leg. “His knee was the size of a freakin’ cantaloupe,” said Jessica.
A welder who works at marinas, Robert found himself couchbound at age 50, unable to work, on a steady diet of Motrin while he waited for Fidelis to approve the MRI, watching his muscles atrophy. The couple’s teenage daughters took over mowing the lawn, driving, the stuff their dad was unable to do.
Their doctor made multiple phone calls and held a meeting with the insurance company, to no avail. Jessica requested a case manager, and was told that theirs was the silver plan; they needed to have a gold plan in order to get a case manager.
“I’m calling and screaming at these people -- it wasn’t their fault, whoever I was talking to -- but [it was excruciating] not being able to get approved and just feeling absolutely helpless. I felt like they were just denying him care by not letting him get the MRI. It’s not health care, not health care at all,” said Jessica.
“Eventually, we just gave up, and we just paid out of pocket,” said Jessica. If they had known their insurance company would string them along for a month, they would have paid the $540 for an MRI right away, she said. “Nobody’s really honest with you. I just kept expecting after every phone call that they would approve it. Like, how could you not approve it after I’m telling you this, and after the doctors told you what he’s dealing with? It’s just a delay after a delay after a delay.”
It turned out that every ligament in Robert’s knee was torn. “The delay in care also caused severe atrophy to my leg muscles which will now take months of physical therapy to recover,” Robert wrote in a letter to the insurance company requesting reimbursement for the MRI.
In the end, they never did get reimbursed for that MRI, though Fidelis did finally approve the scan a week or two after the Annunziatos paid to have it done, said Jessica. Their insurance did eventually cover Robert’s surgeries – one to repair his patella, and another to repair his ACL – and he’s getting around as well as ever, she said. But the episode left them deeply skeptical of our healthcare system.
“I can’t imagine what happens to people who are really ill, fighting for their lives and trying to fight insurance companies,” said Jessica.