More than 182 million Americans have comprehensive health insurance - that's the good news. The bad news is some people could get little or nothing if they make a claim on a serious illness. The word "comprehensive" doesn't always mean the same to patients and insurers.

"John Doe," as court records refer to him, was a healthy attorney when he was diagnosed with a rare and typically fatal type of blood cancer in 1991.Doe sought out specialists who said his best chance at recovery was through intensive radiation and chemotherapy. Due to the excessively high doses of chemotherapy, his doctors prescribed an "autologous" bone marrow transplant to preserve his immune system. It was a roll-of-the-dice decision advocated by his doctors.

Doe thought he was covered by the comprehensive health plan his firm purchased from Blue Cross/Blue Shield of the National Capital Area. But he soon discovered that an amendment added on to his policy by Blue Cross only covered bone marrow transplants for certain diseases. His wasn't on the list, nor was he covered for any "related services and supplies," which Blue Cross defined as the rest of his treatment, from blood tests to chemotherapy. John Doe was out of luck and out of pocket.

Faced with more than $100,000 in unreimbursed medical expenses, or near certain death, Doe sued Blue Cross and won, but only after his case was appealed to the Fourth Circuit Court of Appeals. In his original trial, a district judge initially ruled in favor of Blue Cross. But the appellate court held that Blue Cross was liable for all expenses except the actual bone marrow transplant. He luckily could afford treatment while his case was contested, and his cancer has been in remission more than a year. A Blue Cross spokesperson said a final settlement amount is being negotiated.

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The health-care debate will pivot on the minority of the population who are uninsured, but the majority with loophole-laden insurance policies like John Doe can fall prey to a false sense of security. In the eyes of insurance company bean counters, no longer do doctors really know best.

A good doctor and a dogged lawyer are sometimes the only cure. Attorney Ron Karp, former head of the D.C. Trial Lawyers Association, recalls a recent incident where a Maryland woman was denied coverage for a bone-marrow transplant because her insurance company claimed it was experimental. As the woman was gathering money to pay for the operation, Karp's research found that a federal court in Maryland had recently ruled that such transplants were not experimental, and that doctors, not insurance companies, must decide what is experimental. One phone call from Karp quickly compelled the woman's insurer to pay for the transplant.

Bone-marrow transplants are a good example of the changing mores in the insurance industry. Once judged by actuaries as "experimental," insurers like Blue Cross were free to exclude them from coverage. Since these transplants became part of standard medical procedure, many insurance companies have begun to exclude certain bone-marrow procedures by name.

For insurance companies, exploiting contractual loopholes is part of playing the odds.

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