In January 2021 (recall), after I tested positive for covid-19 in London, I contacted my GP in Amsterdam. She was gracious in acknowledging that her initial diagnosis (stress) of my symptoms was mistaken. (For my official "covid diaries," see here; here; here; here; here; here; here; here; here; here; here; here; here; here; here; here; here; here; here; here; here; here; here; here; here; here; here; here, and here). On the phone she urged me to get a blood-test to establish some base-lines for my disease (amongst other reasons). Because I was not part of the NHS (yet), I found a private provider who came to my home. Much to my amazement there were numerous providers of blood tests in London who cater to the very large ex-pat community. Within 24hrs, in the middle of a lockdown and stories of long lines of ambulances waiting to deliver urgent care patients, I had my test results and a hefty bill. I paid the bill. After consulting with my travel and health insurance companies, I decided to submit (via a nice app) to my Dutch medical insurance. The insurance company specializes in medical care workers (since my better half is a surgeon), and I have always been very happy with them. When a few weeks later, I checked on its status, I noticed it was declined. I contact the insurance company which informed me that I needed a proper referral from my GP.
I contacted my Dutch GP -- where the practice was, of course, also groaning under Covid restrictions and added volume of care --, and explained the situation. Thankfully my GP had good notes, and it was agreed to provide with a referral for the insurance company. I was then introduced to the secured email system they use to communicate sensitive information to patients, and I was reminded that I could use the (less secure) web portal for communications with the GPs while I was in London. In the year since, I have become very familiar with the quirks of both software systems (but about that some other time), but they have also made life much much easier (especially as my brain fog developed).* So, a few weeks after submitting the initial declaration, I resubmitted it.
I think most regular readers realize that my family lives in London, whereas I work and have a place in Amsterdam. (I eventually joined the family GP in London, and so entered the NHS system.) In fact, I bought my 1BR in the Fall of 2019. This was, in fact, the first bit of property that I owned in my life. And as 2020 developed, travel between London and Amsterdam became increasingly cumbersome. And just before it became nearly impossible, my Chair suggested I head to London as we were transitioning to remote teaching. (Subsequently, I negotiated a teaching leave during the Fall because I accumulated a lot of extra hours.) So, for most of 2020 and 2021, the final book boxes remained unemptied in my living room. That Fall (2020), because I didn't have a home office space, and the British Library was closed, I subscribed to one of those office companies so that I could get some research done and have a quiet please for contact with my colleagues and PhDs.
Okay, back to that insurance claim. Early last year I forgot about it because I had more important things on my mind: like not burning down the house accidentally while making lunch, figuring out how to coordinate the exams for a massive lecture course from my sick-bed in another country, and, say, my inability to walk more than fifteen minutes with my family. But 300€ is a lot of money even in good times, so eventually I remembered, especially when, under ordinary social security rules my salary started to be cut after nine months of illness (at the start of October 2021). This amounted to a 15% salary cut. Not huge, but noticeable in a two-household single family with a school-going kid. At that point, I took a sober look at my expenses, and made some non-trivial cuts: I gave up my US phone-number (after thirty years or so), paused my habit of collecting antique books, didn't renew a whole bunch of subscriptions to learned journals and magazines, and stopped my habit of ordering out when alone and took up cooking again (at which time I was less likely to burn down the house). During the early phase of my illness I also eventually remembered to halt my office subscription. None of these decisions felt like hardship, and whatever stress I had about my illness, I am blessed that I am not especially worried about my financial future.
So, in the Fall of 2021 I contacted my insurance company which suddenly became much harder to reach due to their service agents working from home, the heavy volume increase in claims (by folk like me), and, I assume, increased sick leave (some of this information comes from the message they repeatedly provide you with while whiting for an agent). And because I was not feeling so well during this period, I invariably gave up after waiting after endless periods on hold. I return to the claim below.
Now, the insurance claim is not the only such extra expense I have encountered. And I will spare you the many examples. Unlike in the American system where these kind of things can be catastrophic, the extra expenses per occasion amount to 10-20€ at a time. In the Dutch context this is primarily due to the fact that many individual, specialist care providers in the Dutch system are opting out of direct contracts with insurance companies, so that they can charge slightly higher rates. (The rates have a mandated ceiling to them, but they like to charge near the ceiling.) And at the urging of my occupational physician I have tried out some of these care providers (some of which providing highly experimental care). In most cases, I have simply swallowed the cost, but I have also tried to get my university to pay for some of the additional costs (the margin between what my insurer will pay and the amount I will pay), and much to my frustration the university declined to do so (even though the care is being undertaken at the urging of the occupational physician). Don't get me wrong I don't feel arm-twisted by the occupational physician; I am happy she is on the look-out for care that might help.
As an aside, you may wonder why I bother with the Dutch health care system, if I am now part of the NHS (where nearly everything is free except for some modest co-payments for prescription drugs). The simple answer is that the wait-periods for non-urgent care -- and long haul is not considered urgent -- is really extraordinarily long in the NHS. (There is a lot of quiet suffering in the UK!) Obviously, this is partially the effect of switching resources and people to treat urgent Covid-19 care, but it is also function of structural underfunding of NHS, and the way its referral procedures and prescriptions function. It's quite amazing really that a few weeks delay in the Dutch lead to modest apology, and it would be treated as a miracle of efficiency in the NHS. (In a nearby possible world, I would do comparative health care spending research by now.) So, I keep my Dutch GP informed of my treatment and consultations with the long haul clinic at UCLH, and she helps coordinate my Dutch care. So, I try to get the best of both worlds, but it is exhausting to get care for myself. (I will ignore in this post the many things that make it infuriating including the fact that many Dutch specialists treat long covid as a life style burn out or as primarily a lung disease.)
Last week, I needed to call my insurer again to figure out reimbursement on a new health care provider and in particular how to make the insurance codes match on her bills to me and my claim submissions. The wait was short, and I got a wonderful agent on the phone. And after we solved that problem (it would cost me, I guess, 10-20€/visit), I decided to ask her about the blood test claim of January 2021. Thanks to the app, it was easy to hunt down all the information in her system, and after, putting me on hold, and looking through the claims, she admitted it was unclear to her why I was not paid out. But she couldn't make the decision, the claims department had to do it. And then she informed that she did not get priority with the claims department, but that she would also be put on hold and that the wait would be long. Would it be okay if she called me back next week? I noted and wrote down her name, and happily agreed to these terms. I also noticed I had gone well beyond the 30 minutes I can handle phone-conversations. And so went to bed to give my head a rest.
Fast forward to the present. I just got off the phone with another kind insurance agent who had no record of my conversation ever happening last week. He never doubted that it did happen. He and I went through the case again, and he agreed with his colleague's evaluation that it was odd I was not paid yet, but formally this was a decision of the claims department. This time, I asked if he could send me an email or a letter that we had had this conversation. He agreed. And he also suggested that the company would only contact me if they declined to pay. If the claims people sign off, I would get the usual notice on my app, and the money. I happily agreed to those terms. When we hung up I noticed the conversation I had lasted 27 minutes and 5 seconds. It was time to make another espresso.
Now, to reiterate, none of this is catastrophic American style. I don't have the risk of collecting agency breathing down my neck, eviction, etc. But it has given me a glimpse of the ordinary struggles that poor people with chronic diseases have even in reasonably well functioning welfare states. (And, of course, Dutch recent history -- google 'toeslagenaffaire' or 'Dutch childcare benefits scandal' -- suggests it does not work so well for poor people who have a migration background.) Expenses accumulate in open-ended fashion just as the source of income is reduced. It eats up energy to keep track of these, and to try to get claims paid out. This is alongside the emotionally draining aspect of trying to get oneself (or loved ones) the care they need, and navigating complex bureaucratic systems and the not infrequent passive aggressiveness of overworked care workers who may not be able to help you at all. (The ones that clearly think they may be able to help you tend to be much nicer!) As a male professor, I have a lot of social capital, and I have non-trivial number of connections in medicine. My rule of thumb is, if the whole process is difficult for me, it must be agonizing for folk with much fewer social and financial resources.
So, if your underlying disease makes it difficult for you to concentrate and have modestly long conversations, trying to get care (while partially working and being a dad/husband/son/brother/uncle, etc.) actually undermines one's heath and sanity. And it's a peculiar social fact that when your expenses increase due to need, your income gets cut. Meanwhile, that blood test remains un-reimbursed.
*The NHS, by contrast, uses a standardized portal for GPS that is cumbersome and time-consuming, and actually likely to lead more errors.
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