| ystem in the United states for health insurance | | | | disclose what proportion of claims are refused. So |
| works fine, so long as you stay fit and healthy. It | | | | how can someone intelligently decide between |
| is only those who need health care who have the | | | | insurance companies if they do not know how |
| problems! However bad the health system might | | | | likely it will be that their claim will be refused? |
| look on paper - Americans pay double what | | | | This is not the only information that insurers keep |
| people in other wealthy countries pay, yet they | | | | to themselves. With most policies, when people go |
| have worse health results. And this is despite | | | | "out of network", they payout a sum that is |
| America still having forty seven million uninsured | | | | around 70 to 80 per cent of the "reasonable and |
| people - so in practice it is much worse. | | | | customary" rate. Usually your insurer will not tell |
| Let's consider the start of the process. You are ill. | | | | you in advance what their "reasonable and |
| So you go to the doctor. You pay the doctor | | | | customary" rate is, so if you are ill you will not |
| direct and then send his bill to your insurer for | | | | know how much that trip to the doctor will cost |
| reimbursement. The insurer then sends you a | | | | until the doctor has submited the claim. |
| standard letter rejecting your claim. Yes, it | | | | Furthermore, the insurance company is free to |
| happens all the time. | | | | change their "reasonable and customary" rates at |
| Those of us who are persistent contact their | | | | its own discretion. |
| insurer and demand to know why the the claim | | | | Similarly, at their own discretion, they can also |
| was refused. The insurer replies, if you are lucky, | | | | change their procedures and change what they |
| providing a form for your doctor to complete. | | | | do and do not cover. As it is, the law basically |
| Then, despite the doctor returning the form, the | | | | gives insurers a free hand to abuse patients. It is |
| insurance company will still not payout. Those of | | | | like handing over a 10,000 dollar check to a |
| us who are very persistent again contact their | | | | contractor to repair the roof and chimney on |
| insurer and demand to know why the claim was | | | | your house and then leaving it to them to decide |
| rejected. The insurer denies that they never | | | | which repairs they do. A contractor that fixed a |
| received the Doctors' form. A rather unhappy | | | | few tiles and bricks and then drove away would |
| doctor is then persuaded to fill out a second form. | | | | be prosecuted for fraud. An insurer effectively |
| The result? The bill is still not paid. | | | | doing the same thing, by denying care to its |
| Those extremely persistent people amongst us | | | | policyholders, could end up paying big bonuses to |
| call the insurer again demanding to know why the | | | | its Chief Executive. |
| claim was rejected. The insurer says the doctor | | | | We would like Obama to have healthcare reform |
| sent in the wrong form. The story goes on and | | | | at the top of his domestic agenda. His reforms |
| on but at the end of the day, the insurer got the | | | | must make healthcare affordable to all. He shouls |
| form they wanted and were correctly reimbursed | | | | also plan to offer a public insurance option |
| as provided. But, I think we are in the minority as | | | | modelled on Medicare that everyone can qualify |
| the extremely persistent, well-educated | | | | for. The Medicare plan has predictable benefits and |
| policyholders who are aware of our rights under | | | | costs unlike private insurance. Virtually any doctor |
| the insurance policy. | | | | can be seen and Medicare pays the doctor |
| Suppose the refusal to pay had arrived on the | | | | directly. This means you do not have to pay |
| doorstep of someone who is not very well | | | | upfront. The, if your claim is refused, it is your |
| educated, or does not have the mental or | | | | doctor who becomes financially liable unless he or |
| physical awareness to fight back or who even | | | | she has warned you in advance that your |
| does not speak english? That person may well | | | | Medicare will not cover the cost. |
| have just accepted that the insurance company | | | | Health care reform should more heavily regulate |
| was in its rights to refuse their claim. Probably | | | | the private insurance system. Companies must be |
| they would not have fought the issue. Or, if they | | | | forced to disclose the full schedule of treatments |
| did fight once, they might have given it up after | | | | they will cover and under what circumstances. |
| the first or second set of correspondence. | | | | They must also publish a full schedule of their |
| From the insurance company’s standpoint, | | | | fees. Once a policyholder signs up for the |
| the refusal of a claim is almost a no-brainer. For | | | | insurance the insurer should noy be allowed to |
| the cost of sending a letter, they save | | | | move the goal posts and they should have to |
| themselves payouts that can run into the millions | | | | publish the percentage and average values of the |
| of dollars. In the worst case scenario, they come | | | | claims they refuse. |
| across persistent clients who demand that the | | | | After all few businesses can unilaterally change |
| insurer honours its policy and end up paying what | | | | the terms of their contracts part way through |
| they should have paid out in the first place. In the | | | | the contract and there is no reason to make an |
| mean time they earn interest on the money they | | | | exception for insurance companies. This is |
| with hold from you. They are not faced with any | | | | especially important as they are often dealing with |
| penalties or fines for wrongly refusing claims. | | | | clients with serious health conditions, the most |
| In America, insurers do not generally publish the | | | | vulnerable sector of the population. |
| basis under which they refuse claims. Nor do they | | | | |