One slip on an icy sidewalk and Trish Martin was in the hospital with a broken back and wrist.

Doctors at Holy Redeemer Hospital in Montgomery County splinted her wrist, but she needed surgery to repair her damaged vertebrae.

And the insurance she’d purchased just months ago wasn’t much help.

Martin thought she’d bought a comprehensive health insurance plan through the government-regulated Affordable Care Act marketplace, healthcare.gov. But she really visited a website cunningly crafted to look like an ACA portal, which put her in contact by phone with a salesman. He sold her plan that turned out to offer only minimal coverage, and when Martin needed help, his number was disconnected.

She was left with $36,000 in hospital bills that she’s still paying off.

“What the hell did I do? How did I get into this mess?” said Martin, 54, of Horsham, recalling the panic she felt after the December 2017 fall. “I have a broken wrist, a broken back, and I don’t have real health insurance.”

Limited-benefit insurance plans are legal and have an appropriate place in the insurance market, covering people who are between jobs or want to supplement their health insurance. These plans are not primary health insurance, yet they are increasingly showing up alongside comprehensive health plans. Access to these plans was limited under the Affordable Care Act, but the websites selling such plans have gotten bolder in their marketing as President Donald Trump and free-market Republicans chip away at ACA rules, saying people need more affordable alternatives.

But shopping savvy isn’t necessarily enough to protect consumers. The insurance brokers who rely on such websites for leads use scripts carefully worded to instill trust and push consumers to act quickly — before they have time to read the fine print.

“They are preying off a lack of knowledge and a fear of getting sick,” said Dania Palanker, an assistant research professor at Georgetown University’s Center on Health Insurance Reforms. “You’re talking about an extraordinarily complicated issue that for solid reasons most people don’t understand.”

‘How do they get away with that?’

Martin, a self-employed child therapist, had been covered under the same health plan for years, but in the fall of 2017 she decided to search healthcare.gov for a more affordable option.

She entered her phone number on a website she thought was the federal marketplace, and was pleasantly surprised when an insurance broker called her within minutes. At the end of their lengthy conversation, she had a plan that cost $480 a month — about $200 less than she’d been paying.

It had been so long since she’d shopped for insurance that she assumed she had just been getting a bad deal before. Besides, the broker assured her that her doctors and preexisting conditions would be covered.

What she bought was an accident and sickness hospital indemnity plan by Chubb, which has U.S. headquarters in Philadelphia. Once the plan paid its set rate per health incident — $2,000 — Martin was responsible for the rest of her hospital bills. ACA plans limit annual out-of-pocket spending. Not so for indemnity plans.

“How do they get away with that? I just don’t understand how there aren’t certain words they should have to say,” Martin said. “I thought I was asking all the right questions.”

Eric Samansky, a spokesman for Chubb, said that all brokers licensed to sell Chubb personal accident and supplemental health insurance plans are required to disclose the nature of the coverage and that they are not major medical insurance.

“We have extensive procedures in place to monitor the sales of these products and our distribution partners’ compliance with disclosure and marketing requirements,” Samansky said.

He declined to say how exactly the company ensures that those rules are being followed.

Carefully crafted pitch

When it comes to health insurance, it’s not hard to buy something you didn’t really want.

All a salesperson has to do is gloss over the plan’s shortcomings, while emphasizing appealing features, such as no copays or deductible and a low monthly premium, said Michael Fissel, a special investigator for the Pennsylvania Insurance Department.

“One of the big things they say is, ‘This plan covers you from day one.’ What they don’t say is they’re not covering you from the day before and that no preexisting conditions are covered,” Fissel said.

“They’re preying on everyone’s desire to have health insurance that’s affordable,” he said.

Fissel’s investigation of one Florida firm that operated in Pennsylvania, Simple Health Plans, was included in a Federal Trade Commission case that led to the company being shut down.

In a script Fissel obtained from Simple Health Plans, brokers tell customers that their plan offers unlimited access to doctor consultations, benefits that apply in any state and no deductible.

By the third page of the script, the broker asks: “For the first payment, will you be using a debit or credit card?”

Then there’s this instruction, for the broker’s eyes only:

“REMAIN SILENT - 1st person to talk loses!!!”

Why does the first speaker lose? Because few people like an uncomfortable silence, and the broker knows his prey will want to fill it, potentially by providing a card number.

Why so confident? Because the broker, instructed by the script to “BUILD A RAPPORT WITH YOUR CLIENT!!” likely has won over anybody who has stayed on the phone up through page 3, especially since they want insurance coverage.

"I know exactly what you’re looking for,” the broker says to a target they really know almost nothing about.

By skewing the power dynamics of a typical conversation, the broker is able to imitate genuine conversation, while maintaining complete control over the outcome, said Delphine Dahan, an associate professor of psychology at the University of Pennsylvania, who studies language and communication.

A question such as “Are you healthy?” would give the client a chance to say no, and even take over the conversation, Dahan said. But the broker doesn’t ask anything so open ended, sticking with: “Since you’re healthy and don’t need benefits like maternity and mental health, this plan makes sense …”

On top of all that, the consumer is coming into the conversation thinking that the broker from healthcare.gov is calling to help them sign up for health insurance and that every exchange is a step toward that goal, Dahan said.

“It’s all set up in a way that you have no reason to be suspicious,” she said.

Only after the broker has asked for a credit or debit card does the script mention that the plan does not provide minimal essential coverage — but says that’s actually a good thing because it makes the plan cheaper.

“It’s really just insurance terms, but let me go over them with you again just to MAKE SURE you understand everything correctly,” the script reads, further cementing the broker’s bond with the customer.

Tough to regulate

These cleverly crafted pitches are partly what makes cracking down on bad-actor brokers so challenging, said Pennsylvania Insurance Commissioner Jessica Altman.

The insurance department approves all plans sold in the state and issues licenses to brokers. But the state typically finds out that a plan isn’t being sold appropriately or that a broker is being dishonest only when a consumer files a complaint.

While some states ban certain limited-benefit plans, Pennsylvania does not. Altman said she is working with state lawmakers on strengthening consumer protections, but declined to give details.

In the meantime, she is encouraging people shopping during the enrollment period for 2020 coverage, which runs through Dec. 15, to turn exclusively to healthcare.gov.

Tread carefully when searching on Google — the top results are likely ads for private insurance websites.

Google has removed the most egregious ads by websites that used healthcare.gov in the ad’s title, following an investigation by Sen. Bob Casey (D., Pa.), which was spurred by The Inquirer’s reporting. But deceptive ads for “Healthcare Marketplace 2020” and “Obamacare Enrollment” still litter search results.

Martin is taking extra care when she enrolls this year. After canceling her plan in early 2018, she filed a complaint with the insurance department and has since enrolled in a traditional health plan. It costs $650 a month, which she pays on top of the $350 she sends to Holy Redeemer Hospital to pay down her debt.

After her fall, Martin took $15,000 from her retirement savings to pay down her $36,000 debt. The hospital gave her the discount they offer uninsured patients, reducing her bill by about $6,000. She’ll be paying off the remaining $15,000 for the next several years.