Aetna Insurance denies treatment to breast cancer patient

[IcyPeas]

Her doctor recommended the treatment but Aetna said no. She sued and finally got the treatment. This is so wrong. Profits over patients.

Infuriating! Time is of the essence in these cases and the patient has to get a lawyer and start fighting with the insurance company too? Imagine having to go through the added stress of that!?

[Dorian Gray]

1. insurance companies are a scam.

[questionseverything]

4. They exist to deny care, just evil

[NCDem47]

6. And taking your $$$

[Dorian Gray]

22. Agree

Just a terrible way to run healthcare.

[TreasonousBastard]

2. I have no argument with insurance companies choosing...

profits over treatment, but nobody's asking why a cancer treatment costs "..tens of thousands of dollars..."

[3Hotdogs]

14. I do. 15% of premium goes for processing. It doesn't give you so much as one band-aid.

Medicare runs on 3%.

[stopdiggin]

17. that's their business model (in which you're free to find offense)

but it doesn't in any way address the post to which you responded. To recap - it is hugely inflated medical costs - that are screwing both the patients and the insurers.

[luvtheGWN]

18. A few years ago I read a report about consumer healthcare costs.

Because your physician's staff must deal withs several different insurance companies and plans, a full 33% of what he/she is paid per visit is to cover staffing costs. Here in Ontario the cost is just 3%, and that is one person filing patient info with the Ministry of Health to ensure the physician is paid.

With pharmaceutical companies, although they claim drug prices are so high because of research and development, that's not true either. At least 75% goes to advertising and promotion. And then you have the outrageous costs for insulin: University of Toronto doctors Banting and Best discovered insulin and how to treat diabetics with it 100 years ago. They patented it and sold it to a U of T lab for $1. And now you have drug companies selling this absolute life-saving drug for hundreds of dollars.

I'm sorry but the US healthcare industry is so totally screwed up. And patients, in turn, are royally screwed. The US government does not exhibit any interest in the care and well-being of its citizens, but only of its corporations. JMHO, of course.

[csziggy]

25. Yes, my previous doctor had more insurance clerks than medical staff

He had a single doctor office, with a nurse practitioner and two or three nurses to assist. His office staff was two receptionists and six insurance clerks - each clerk "specialized" in different groups of insurance companies. Eventually he retired from single practice and joined an HMO, which is when I moved to a different doctor.

During the time my husband and I went to him, every time his job changed insurance companies, the clerk we had to interact with changed. The worst was when the coverage was with BC/BS of California (where the company headquarters were) and they assumed it was BC/BS of Florida (where we are). It took months to straighten that out!

[area51]

27. This.

The US desperately needs universal healthcare, but our govt. doesn't give a toss about us.

[Dave says]

32. No, Republicans don't want it. ...

… because our oligarchs don’t want it. We have the best healthcare in the world if your well within the top 1%. If you’re in the bottom 80%, we’re almost as bad as a third-world country. Many don’t realize that until they get seriously sick. By then, it’s too late.

[multigraincracker]

3. I hope this causes lots of people to change insurance companies.

They can spend on advertising and bad news still makes it around the world before good news gets across the street. Save a penny and have it cost you a dollar.

[Silent3]

5. How many people have much choice?

I have the plan my company offers, one of a very small range of options, that has the price that I can bear. I haven't made a change in a while, but I think this small range of options is either all from one insurance company or maybe two. As time goes by, the price goes up, the deductibles go up, and the coverage goes down.

This is typical for most Americans who aren't on Medicaid or Medicare.

Even as much as this sucks, my employer is still covering the bulk of the cost of my insurance. If I turned down coverage through my employer, and bought on the private market, I'd only get back a fraction of what my current insurance costs in my paycheck to go out and buy something else on the private market.

[AngryOldDem]

9. Back in the '80s, I had a damn smorgasbord of options.

It was with my first full-time job, and I thought my head would explode looking at all the different coverage options. But then every year the options kept getting reduced. My current employer has one provider only, and it’s been like that for years. And every year it seems they get more draconian about what they cover. I’m on a fairly expensive medication that they won’t cover. They want me on a generic, and my doctor says it is not the same. So I pay for it out of my HSA, and everytime I get a refill the pharmacy lectures me about it. My response is, “My insurance does not dictate my health care.” That shuts them up.

I’ve come to the conclusion that health insurance, especially, is a scam.

Oh…and private markets? I was self-insured for a few years and one provider I had pulled out of my state, leaving me scrambling to find something else. And it was hella expensive, to boot. (Long before ACA.)

[AngryOldDem]

7. I had Aetna back in the day, when I was an independent contractor.

They suck.

They also pulled out of my state because they weren’t making enough money. If that doesn’t say it all…

[RicROC]

8. Thom Hartmann has been railing against Medicare Advantage coverage,

because of this scenario. Regular Medicare pays for treatment but M-Advantage allows insurance companies to have control of treatment options.

[Emile]

10. +1 Spot On!

[uponit7771]

40. +1,

[MattNC2021]

11. My wife passed away at the end of 2020 from breast cancer

Luckily the hospital had advocates that fought for treatment. We did experience “billing issues” twice when Blue Cross “accidentally” reset the deductibles mid year. My wife would hit the out of pocket max in January. They reset it in July and took months to correct it.

[Delphinus]

12. Firstly,

condolences on your wife's death.

Secondly, welcome to DU. I'm glad you are here to share your experience and your viewpoints.

[Bettie]

13. Health Care should not be for-profit

but, it is and thus, we have insurance, not care and we get as little of that as they can manage for as much as they can possibly charge.

[Dave says]

33. Yup.

[TNNurse]

15. I will never forget the call from my insurance company.

It was after my mastectomy. The woman on the phone identified herself as the one who "approved the surgery". I was speechless. I had metastasis and someone had to "APPROVE THAT". It was best I could not find words...

[lostnfound]

28. Plus they are wasting the time of the doctors

The leaders of these insurance companies aren’t fit to tie the shoelaces of the medical personnel.

[Bettie]

36. I play D&D with some neurologists

and we talked a while ago about how much easier their jobs would be if we had single payer health care.

Apparently, it's just an all around pain in the ass.

[malaise]

16. For profit

Not for saving lives - that is all

[NoMoreRepugs]

21. As Mittens Romney said "Corporations are People my friend" -

I would posit they are fabulously wealthy “people” - and what do those kinds of people want? MORE.

[chwaliszewski]

19. Made me think of this...

[Maine Abu El Banat]

20. Take the billions of insurance profits

Out of the healthcare system and what do you have? Affordable Healthcare!

[barbaraann]

23. We don't have a health care system.

We have an asset extraction system based on health care.

[Dave says]

34. Perfect characterization!

[barbaraann]

35. I speak from experience. n/t

[LittleGirl]

24. There's your death panels.

Thank goodness that woman survived long enough to get the treatment!
Insurance is daylight robbery.

[csziggy]

26. Blue Cross/ Blue Shield delayed approval for an MRI for me

That was needed to diagnose my aortic valve problem. The cardiologist prescribed it in January - BC/BS delayed approval until I went onto Medicare in July. I had rescheduled the MRI until after the first of July for Medicare to cover it and got a letter from BC/BS the day after I got the MRI, giving retroactive approval for the original MRI date in May.

[FreeState]

38. I have a pre-existing

It’s not going away (mutation in a gene that results in about an 80% chance of developing colon cancer). I started the process to get my yearly colonoscopy last November. Im still waiting. I get one every year. I don’t get why BSBC can’t just pre-approve me - it’s ridiculous.

[csziggy]

41. BC/BS and Anthem are the worst insurance companies for denial of routine tests

I'm glad I am now on Medicare - with a very good supplemental plan. It makes life so much easier since all the providers just go, "OK, they never refuse coverage."

[DFW]

29. John Grisham's "Rain Maker" is not fiction, but reality.

The gangster insurance company is not named "Great Benefit," but in reality, Aetna. A few others, too (such as my Blue Cross, which denies EVERYTHING).

[Ms. Toad]

30. My daughter has been denied critical screening tools because they were considered experimental.

It is less of an issue with breast cancer (and conditions which are common). But virtually everything is experimental for my daughter (about 30,000 individuals in the US have her condition). With a patient cohort so small, it is both financially prohibitive (return on investment) to run clinical studies. Even if the studies can be run from a financial perspective, there are too few patients to populate the studies.

It's a real issue - and while it shouldn't happen to anyone, when it happens to such popular diseases like breast cancer - it ultimately brings attention to the problem which disproportionately impacts those of us with rare diseases.

[DET]

31. We've been lucky...

Carefirst has approved all of my husband’s very expensive cancer treatment, including one type of treatment that the doctor told us would be refused. I can’t imagine having to fight the insurance company while dealing with a serious medical issue.

[BootinUp]

37. K&R

[Phoenix61]

39. I had breast cancer years ago. After treatment my doctor

wanted a breast MRI along with my annual mammogram. My insurance denied it and explained they would approve one for someone who had a sibling who had breast cancer before the age of 50. My doctor was livid. The radiology place charged me the negotiated price and I paid out of pocket but seriously WTF.

[KentuckyWoman]

42. Putting some brakes on fee for service medical care

Even when you have a non profit, you find doctors sending someone for advanced imaging instead of simple xrays because the diagnostic is billable at a higher rate in a fee for service system.

I currently am on straight Medicare, and all my doctors are connected University of Cincinnati. It is as close to non profit as I can get. And yet I regularly have to put the brakes on my own doctors. For instance, I take aspirin and generic plavix. They wanted me on warfarin 20 years ago and I said no. Now it's Eliquis. I said no.

There are too many people who feel entitled to every expensive pull out all the stops medical care. Too many doctors will do it because ever service can be billed regardless of whether the cost/benefit is really there. On the other end patients show up in the doctors office wanting some cutting edge something to make it go away and go doctor shopping if they are told there is no way to make it go away.

These issues exist even in a non-profit world. Add the pressures of a for profit system to it and it is a recipe for even more trouble. If we want to fix the broken system we have to address fee for service in addition to the profit system in medical care.