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