Broken Wrist a Pre-existing Condition

And I continue to ask the question, how is it people believe that private companies provide better health care insurance. Below is the story of a lady who fell and broke her wrist. She’d been covered by the same insurance company for years. They first denied the claim…and the reason given by the insurance company…because it’s not covered because it was a pre-existing condition.

Not too surprisingly, the story is about the suspicion of many that insurance companies simply deny claims, and are slow to respond to challenges knowing some people won’t challenge the denials, and others will give up. There is NO suspicion in my mind about this. I have the records to prove it.

On every single dental claim I’ve ever filed, the insurance company has initially denied the single most expensive item on the bill. When challenged, they always pay the item, so it’s clear they know they are supposed to pay them, they just hope, as a matter of policy, that if they deny claims, some percentage of people won’t challenge them. That was the case with the lady in story. When challenged, they paid. I don’t believe for a minute they did it just to make her go away, they knew they were contractually obligated to pay it as a covered expense. I wonder why no lawyer has ever sought a class-action lawsuit against insurance companies for breech of contract?

In some cases, the reason for their denial has been that the dentist used the wrong Code for the procedure. Funny thing about that though, when I asked them what would be the correct code, they always answer with, “Well we don’t know that, it’s just that this one is the wrong one.” I finally explained that I watched my dentist run his finger down the list of the ADA codes, so I had to assume they had a different list of codes. At first, they told me they didn’t have different codes, and only used the ADA codes. So I asked them to send me a copy of their codes…to which they responded that they couldn’t because, “that would be giving out confidential company information.”

So let’s be sure I summarize this for the proponents of private insurers. They claim they use standard published ADA codes which I can get from the American Dental Association, but they can’t provide their version of that list because it is confidential corporate information. The Ombudsman for the Virginia Insurance Department says otherwise, and I finally got the list. Once I did, amazingly, they no longer used that as a reason for denying claims.

So what was the next excuse. Well it was a whopper. After having some emergency dental work done in Boston while on a business trip, they denied the claim because the name and address of the provider wasn’t on the claim form. It should be noted, I called them to be sure I was using the correct and current claim form (as they had been purchased by United Healthcare), but there was no place on their claim form that asked for the provider information. I pointed this out, but pointed out that it was on the bill from the Dentist, and they obviously had it, as it was printed on the explanation of benefits (EOB) they had sent.

Denial Code #2, the lady wasn’t sure what it meant, and said that sometimes, if they didn’t have an exact code, they would use just any code…so help me God, that was what she said. She couldn’t explain how we’d ever resolve the situation if the insurance company itself wasn’t sure of the reason for the denial.

Denial Code #3, they were insisting that the I provide them a copy of the Dentist’s license. The Dentist laughed at that, explained he got checks daily from United Health care, and had never provided a “copy” of his license. I checked with two other dentists, and they’d never been asked for such a thing either. In fact, the dentist I go to here in Tampa is not in their network or any other network, and I’ve never been asked to provide his license, but of course I was going to him back when they were still using the “wrong code” dodge.

I explained to the lady that it was silly, since even if his license was revoked or suspended, no State sent out “license police” to collect the licenses, and asked her if she’d ever heard of Photoshop, and explained I could probably create a license for the guy in about 10 minutes. I told her to look on-line for Massachusetts, and find their public listing of licensed professionals. She said they had a team of people that did just that. I never pressed the issue about why, if that were the case, why were they asking me for the information. She called back two days later to tell me that their people couldn’t find such a website or listing for the Commonwealth of Massachusetts, so while I had her on the line, I found it. They refused to reimburse me for my time doing their research.

So this story comes as no surprise, but people continue to believe that somehow private companies have your best interests at heart when it comes to taking care of your health. Please…get real.

And now, finally, some on the conservative right come forward, and tell us the real reasons we can’t have government run insurance (not health care, but insurance to pay for health care). First David Brooks writes in an op-ed in the New York Times opposing a public health insurance option. Brooks’ opposition is based on the fact that it wouldn’t bring to the problem any efficiencies (because, you know, private health insurance companies make the healthcare system so efficient), but his article admits:

The authors of these bills have tried to foster efficiencies. The Senate bill would initiate several interesting experiments designed to make the system more effective — giving doctors incentives to collaborate, rewarding hospitals that provide quality care at lower cost. It’s possible that some of these experiments will bloom into potent systemic reforms.

But the real reason, as it comes out in a later paragraph is, “Reform would make us a more decent society…,” and of course we can’t have that.

Havard economics professor Greg Mankiw agrees with Brooks, and offers this explanation as to why we can’t have any reform of the current healthcare insurance system:

Put simply, the health care reform bill would make the United States more like western Europe. That may mean more security about health care, but it also means that future generations of Americans will likely spend more time enjoying leisure.

So let me sum up the position of this Harvard (are your serious?) Professor. In order to get more security about healthcare, the trade-off will mean that our children get to enjoy more leisure time. Please don’t throw me into that briar patch.

Now those are definitely some good reasons to get behind for opposing health care insurance reform…ghess. Really, who could possibly want average Americans to enjoy more leisure time, and we sure as hell can’t go around building a more decent society. What was I thinking!