The healthcare industry and insurance companies often appear to be in opposition to one another rather than working together for the best outcome for the people they serve.
What do I mean by that?
The medical professionals advise a patient under their care that they need a particular procedure only to be denied by their insurance company stating that it is unnecessary, and they rarely offer any alternative solutions-that is left for the patient to find, IF they can.
All too often, if they do find an alternative treatment, that too is denied.
For instance, if it is new and innovative, it is often considered “experimental,” or “cost prohibitive” and therefore, NOT covered.
Another way insurance companies deny services is by classifying their condition as “pre-existing.”
Once while working in the industry, I had a claim for phototherapy (a special light therapy that is a common treatment for jaundice in a newborn) denied for that reason. It was utterly ridiculous!
Why is this the case?
All too often, it’s because the insurance industry is putting their profit margins ahead of what’s in the best interest of the patient’s care.
When and if they do offer coverage for treatment, it’s only a modicum of what’s available, and even then you have to go through less effective treatments before you get one that actually works.
It can leave patients feeling frustrated because they can’t afford repeated trips to and from their provider, or the treatments offer minimal results, or perhaps the side effects were worse than the condition they were seeking treatment for.
As a result, many just give up. Others do as my mom used to do and say, “grin and bear it.”
This perplexing conundrum is even worse when it involves our children.
About a year ago I was told my granddaughter needed braces.
Like the cases mentioned earlier, this too was denied. Why? They are considered “cosmetic.”
I went through multiple levels of appeals.
In my last attempt, I brought a letter from the orthodontist explaining in detail why she needed braces.
In addition, I had done research that showed the benefits of getting them now while she was still growing as opposed to waiting until she was an adult.
Finally, I prepared a cost analysis showing it would be more expensive, likely more painful and less effective to get braces as an adult.
The insurance representative said, “I’m impressed,” which did bring a smile to my face, but sadly, it was all for nothing.
Despite my best efforts the appeals were ultimately denied.
According to the insurance company, unless she is malnourished and unable to eat, needs oral surgery now, or her teeth are coming in sideways or from the roof of her mouth, she DOES NOT qualify. (This IS NOT an exaggeration!)
Braces are costly to be sure, but my issue goes beyond that.
Insurance companies send reminders to get your child a yearly well check recommended by their primary care physician. They also encourage you to keep their immunizations up to date.
If your child attends school, they must have proof that they are up to date to attend, unless they have a religious exemption. Also, if you receive state aid for your child, such as Aid to Families with Dependent Children (AFDC) you MUST provide proof that you are compliant with this in order to be approved to receive services. Failure to do so is considered negligent, and will result in a delay in the receipt of or termination of your benefits.
My question is how can an insurance company who has NEVER actually met your child overrule the medical professionals (in many cases more than one) who have treated your child for years?
At the very least, decisions should be made on a case by case basis with a realistic set of guidelines for all current and future patients. To do anything else is negligent and it could ultimately leave the most vulnerable members of society with irreparable damage, in this writers opinion.