Should an Insurance Co. ever be allowed to deny coverage for a treatment, procedure or Rx?

[LeftCoast]

This seems to be at the heart of a number of health-care related discussions I've been seeing lately. I'm curious what people think about this.

[dipsydoodle]

1. Yes

but only for pre-existing conditions. Insurance exists to cover the occurence of what should be from the outset a currently unknown, not definate, event.

[LeftCoast]

2. What about highly experimental medications?

Also, why exclude pre-existing conditions? Wouldn't that make a huge group of people uninsurable?

[dipsydoodle]

15. Insurance of any type exists to cover

the occurrence of the possibility of an event - not a certainty.

Experimental medications whatever are a different subject. My wife's insurers would've paid for almost anything to sort her brain tumour to keep her alive but the the surgeons decided the risk of failure was too great which could have had problems with continuance of the then experimental program, early '90s, of implanting radioactive isotope beads.

[LeftCoast]

16. Not sure I agree with your definition of health insurance but ok

I suppose you could argue that those people would have to have some other sort of health care solution. Seems to me to just be shifting the burden. I'd rather come up with a way to fund the entire country's health care all at once. Either through single payer or multi-payer, but however it was done, all the costs of health care need to be worked out.

[dipsydoodle]

18. Sorry

I didn't allow for the differences between our countries. Our National Health System obviously doesn't preclude existing conditions as its effectivley applied from pre-birth. I meant, what in our case ,is any additional volantary private medical insurance.

It's a tricky subject your side as neither of your parties really seems to have done anything positive to cater for the overall health care of your nation, especially children, in the period since the 1940's when ours was implemented.

I'm not crowing about our system - it's just there and we all take it for granted as we grew up with it in place. When we were children and food was still on ration <finally ended 1953> we even got free powdered milk and orange juice presumably so's we could write here 50 years later........lol.

[LeftCoast]

20. Ah, I think I see what you mean

I do hope we'll get universal coverage here soon. Our system is in real trouble at the moment. I'm an RN and I see stuff that makes me just shake my head. Just gross inefficiencies in the system simply because we don't have a comprehensive plan.

[Gormy Cuss]

43. edwardlindy's definition of insurance is correct.

That's why health insurance is a shitty way to pay for health care. The former is a risk-based model with incentives to minimize risk and maximize profit, the latter is a cost-based with incentives to treat the most people with the money available.

[Bitwit1234]

24. My insurance company refused, at first

to approve medication for a stomach problem. But my doctor persuaded them to approve it at a higher cost. But just think, if this was life threatening. It didn't make sense. I have had the same prescription coverage for 30 years. New companies take over from time to time when they out bid the old, but my medication is the same. The old company approved it.

[WillowTree]

19. No.

Why should one industry be required to finance the R&D expenses of another? Drug companies should have to prove the efficacy of their products before anyone should have to pay for them.

[Donnachaidh]

7. Unbelievable that anyone in this day and age would advocate such nonsense

Considering where you are posting from - it's mind-boggling. :eyes:

[dipsydoodle]

23. I had to explain that above

I wasn't refering to our National Health system which covers us from pre-birth. I meant, what to us, is additional private medical insurance. See post #18 - OK ?

[backscatter712]

41. We're using the wrong economic model.

There fundamentally shouldn't be a distinction between "covered" and "not covered." It's time to go single-payer - expand Medicare to cover every human in the U.S., no questions asked, funded by tax money.

The end result? The only people involved in the decision as to what medical procedures are to be done are the doctor and the patient. No beancounters allowed.

[MADem]

3. I don't think experimental techniques should be ruled out, especially if they have shown potential.

I object to bullshit quackery, though--that kind of stuff shouldn't be covered by insurance monies.

I also think pre-existing conditions should be covered.

[LeftCoast]

4. How do you decide which experimental techniques to cover?

For example, would you cover an experimental surgery for cancer that cured 10% and cost $500,000 to perform?

[MADem]

9. I go for the "board of doctors" decision planning matrix.

NOT the insurance managers.

Half a million USED to be real money. Now it's just the price of a house in some markets....

[LeftCoast]

10. Where's that money come from though?

Basically you're saying that for every cure you're going to spend $5 million dollars.

[MADem]

35. Not every cure would cost that much, though. You're assuming a worst case scenario, always.

I'm thinking economies of scale, here. Maybe the cure only works ten percent of the time--and maybe, after trying it on a few people, it turns out that it works on fewer....or more...but they didn't try it out on a large enough universe to know one way or another.

Another thing I think the gubmint should do is help states with the funding to open more medical schools. Students attending these schools should get reduced or free tuition, and "pay back" by practicing in underserved areas for five to eight years--sorta like the military, but without the uniforms and deployments. Doctors are in short supply, and that is just stupid. We're IMPORTING them from overseas because we don't have sufficient schools to grow them at home.

Finally, I think we as a nation need to make better use of 'practitioners' of all stripes. Physician's assistants, nurse practitioners, nurses, those types of folks. They aren't stupid--they know how to take care of sick people, and they know when the issue is 'above their paygrade.' We really don't need to see some overworked bastard with three degrees when we have a cold or flu, now, do we? And we might want to make better use of pharmacists as well!

We need to work smarter, not harder--and get some of those voracious middlemen baastids out of the way, too...

[Donnachaidh]

11. Insurance compnaies use the term *experimental* to cover anything they don't want to pay for

Note the case of the teenager that just DIED because her health insurance labeled a liver transplant *experimental*.

When Mickey Mantle needed a liver transplant, despite his years of drinking - he got one. Or David Crosby - HE got one. I doubt if the word *experimental* came up at all with either of these guys. :puke:

[Connonym]

5. If a medical doctor deems something medically necessary

I think the insurance companies should be forced to pay for it. In a nonlife-threatening situation I think it would be acceptable for the insurance company to ask for a second opinion so long as that second opinion isn't from a doctor employed by the insurance company. I know a lot of doctors who are frustrated as hell over insurance companies who second guess diagnoses and treatment without ever having looked at a patient's chart or having done a physical examination. A lot of their time is wasted having to correspond with insurance companies disputing denied claims.

Hell, the truth of the matter is that I don't think there should BE insurance companies. I believe the cost of health care would be a hell of a lot more manageable if we had a nationalized health care system. Government agencies aren't always known for their efficiency but at least they wouldn't be looking for ways to make profits for CEOs at the cost of life.

[yy4me]

6. No, the whole premise should be changed. We need to have

Health Care, Not Health Insurance. I bet we would all gladly give up every one of the useless and expensive benchmarks on each years Federal Budget and use this saving to cover costs of care for all Americans. Enough bridges to nowhere and 700,000 bike paths. Enough with the Insurance stuff, it is a huge money making machine. We need Health Care for ALL citizens, not just for those who can afford to buy it and happen to be healthy at the time of sign up.

Health Care, not Health Insurance. An American battle cry.

[LeftCoast]

13. You're just shifting the problem

Then the question becomes "Should the government deny coverage for any procedure, etc.?"

[yy4me]

26. Good Point! n/t

[supernova]

44. Not as simple as that

There is a worthy discussion to be had about how you allocate financial resources in a healthcare system to make sure you make it as effective as possible.

But denying individual treatments willy nilly doesn't get you anywhere.

It's really more about putting more $$ into preventative care (make sure people who are diabetic always control their blood sugar so they don't wind up in the ER as often, for example. Or, transferring people to hospice when their time comes rather than letting them take up expensive ICU resources, in the aggregate.

Again it's medical staff and patients that should be making these decisions, not accountants and other nonmedical staff.

[FloridaJudy]

8. Some sort of control needs to be in place

Against futile or dangerous treatments. I had a good friend who was dying - no doubt. The cancer had gone to her brain, and she was not responding to any treatment. It had gotten to the point where keeping her comfortable was the best that medicine could do. Her doctor son kept insisting she needed an MRI, to "evaluate the progress" of her disease. For what? Nothing could have changed the outcome at that point. It would have been a waste of money, and an ordeal to my friend in her confused and debilitated condition.

Fortunately, both her doctors and her friends - most of us were nurses like Shirley - talked him out of it.

So some sort of review needs to be done to determine if a treatment or test is worth pursuing. But the insurance companies are the last ones who should be given that authority. Common sense says they're going to deny treatment if it's in their best financial interest - though not in the interest of the patient.

[rug]

12. Nor should hospitals after denial of coverage.

[LeftCoast]

14. Even when there is almost no likelihood of success?

How much are you willing to pay for your health coverage?

[BadgerLaw2010]

17. Exactly. Lot of people in this thread forgetting who actually pays.

I don't want to support $10 million in treatments for someone who any honest doctor would determine has a terminal condition, just because his/her family and the hospital that is going to be collecting the "unlimited" fees wants to keep trying.

If insurance covered everything, people couldn't afford it.

I've personally seen some really awful insurance denials, but making them pay for absolutely everything isn't the answer.

[rug]

50. I must have missed the post where someone is advocating paying $10,000,000 for terminal patients.

[rug]

48. Where does the OP state anything about futile procedures?

[Tyler Durden]

21. When PROFIT is taken out of health care....

Then 10 million dollar treatments will become a thing of the past.

All of you are forgetting that the REASON treatments cost so much is the MARKET. Take the MARKET out of BASIC HUMAN RIGHTS like health care, and the exorbitant cost goes away.

[LeftCoast]

22. What if even after the profit was taken out it still cost thousands of dollars

and it only had a 10% chance of working? Where do you draw the line? Even without a profit, things still cost a lot of money. Healthcare in particular is expensive because it is so skilled-labor intensive.

[Tyler Durden]

29. Then I suggest you get appointed to the "Judgement Committee"

I can only say that you are proposing a hypothetical case which can only be judged in the practice.

I would say that a 1 Million Dollar procedure NOT performed for profit would likely not cost 10% of that.

Does that help? Not being sarcastic, by the way. It's just the only thing I have left from my Lutheran upbringing is a fairly good knowledge of the King James Bible, which has a lot of good things to say, even to us atheists:

Matt.25

1. <40> And the King shall answer and say unto them, Verily I say unto you, Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me.
2. <45> Then shall he answer them, saying, Verily I say unto you, Inasmuch as ye did it not to one of the least of these, ye did it not to me.

[HughBeaumont]

27. Plus, without denials or insurance monopolies, PREVENTATIVE care will be more prevelant.

There'll be more early doctor visits to detect pre-existing conditions or anomalies, so you'll have far less costly late-stage debacles like we have now.

[cyclezealot]

25. remember when auto insurance used to be regulated.

There are only a handful of health insurers left. Why should they not be regulated. They are pretty much a monopoly. I believe if insurance companies were regulated and forced to be working in the public good, they would choose to go out of business.

[Vinca]

28. If you're ponying up $1,000+ a month and absorbing deductibles

and co-pays, the greedy bastards should pay for whatever happens to you. Millions of people who have insurance never get past the deductible. The only reason they deny care is to keep the corporate jet fueled and the CEO salary in 8 or 9 figures. It's a legalized shake down.

[baldguy]

30. Insurance Co.s don't exist to PROVIDE health care

They exist to MAKE MONEY - even to the detriment of health care.

The only rational solution is to remove the corporate profit motive from the equation.

[robcon]

31. Insurance companies should not pay for some treatments.

Experimental.

Non-scientifically based.

Unproven.

Excessive, e.g., going to a neurosurgeon for a simple headache. Going to a doctor or the emergency room for a simple cut.

[peaches2003]

32. If and Only if

a panel of docs NOT affiliated with any insurance companies agree that the treatment is not appropriate for that patient.

[mainegreen]

33. Of course.

What a ridiculous question.

If you can't think of something that shouldn't be covered, your not trying hard enough.

[FlyingSquirrel]

34. Those who voted NO: What if it was your son/daughter/loved one?

Even if there was less than 1% chance of success, if they wanted to try it (or you did on their behalf if they were unable to make the decision) wouldn't you want to have the procedure done or try the treatment or give the Rx a chance? Shouldn't you have that opportunity based on something other than PROFITS?

[robcon]

37. If there was a 1% chance of success, I'd try to get it done.

But I wouldn't expect my insurance company to cover it.

[spanone]

36. not if you've paid your premiums....the doctor knows best...not the accountants

[supernova]

38. NO, can't think of any instance the ins co would be entitled to deny coverage

They have no right to practice medicine.

[helderheid]

39. The doctors should decide what treatment is appropriate, not the insurance companies.

[guitar man]

40. with the premiums I'm paying?

not no, but hell no!! :mad:

I am getting hit with a $100 a month increase in the part of my family health coverage premium that I pay starting at the first of next year. The total premium between what I pay and the part I earn that my employer pays witll total around $15k a year. Yes, that's $15k a tear that the ins. company rakes in annually because I am employed. At that rate, they shouldn't be able to deny paying for anything.

[supernova]

42. Paying premiums

I consider the ins co to be my employee.

What other employee is entitled to tell their employer that they won't do their fucking job?!?

[guitar man]

47. nail, meet hammer

couldn't have said it better myself :applause:

[mmonk]

45. Depends on if it's life saving or not.

I don't think they should allow people to die for lack of treament as a matter of human decency. What are they insuring if not your health?

[lumberjack_jeff]

46. Yes, but the insurance company should be us - the government.

The "bean counters" should have a role. The taxpayers should not pay for therapies that are contrary to medical consensus.

I think that the question you're asking is if an effective treatment should be denied on the basis of cost, and the answer to that question is no.

[Squatch]

49. Not only NO, but HELL NO

How else am I going to pay for my wife's boob job?