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Old 11-16-2007, 06:02 AM   #1
TxBrew
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SWMBO is watching Sicko right now. What I saw he went around to people who's insurance denied valid claims that ended with death IE guy with cancer died because insurance would not cover some procedures.

Anyone here ever been in a similiar boat before? Health insurance not pay for something legit.
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Old 11-16-2007, 07:53 AM   #2
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My wife's best friend, Sue, is a single-mother of two boys (23 and 6). She was a small Japanese woman (but all-American!) who was rather fit but certainly not a health nut.

Her older son was murdered because he witnessed an illegal dog fighting ring doing some "dumping" of dead dogs... Obviously this caused stress. She began smoking cigarettes.

6 months later she was diagnosed with cancer. The insurance company paid for the first round of chemo and surgery which left her unable to speak, smoke or eat anything harder than bread (the cancer was throat cancer) for 6 months. Before that 6 months was over, the cancer had returned.

The insurance company refused to administer a second round of chemo citing the "inneffectiveness" of chemo that early after a first surgery. So, persistant, she found other doctors willing to perform a tested-but-not-yet-mainstream procedure involving chemophotosensitivity that has an extremely high sucess-rate.

The insurance company refused THIS time to pay for "non-standard" practices because she smoked (nevermind that the doctors certified that the tumor existed the day she lit the first one). It's the same, they told her, as refusing a liver-transplant to an alcoholic.

She had to pay for the procedure, after-care and all that out of her own pocket which was, I assure you, not a small sum.
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Old 11-16-2007, 01:24 PM   #3
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Quote:
Originally Posted by TxBrew
SWMBO is watching Sicko right now. What I saw he went around to people who's insurance denied valid claims that ended with death IE guy with cancer died because insurance would not cover some procedures.

Anyone here ever been in a similiar boat before? Health insurance not pay for something legit.
Tx, dealing with this problem is about 95% of my job. One of the largest insurance companies in the country, Blue Cross / Blue Shield, refuses to get into a contract with us regarding reimbursement for two of our 3 hospitals. As a result, people living next door the the hospital have to travel hundreds of miles to another hospital.

Other major insurance companies simply refuse to reimburse at an acceptable level so we have to tell our patients that either they're going to be liable for the remainder (hundreds of thousands of dollars) or they can't treat with us.

I know many of you are going to cry BS on us and say we should treat everyone, but Dr's aren't charities. If you want the best Dr's, you have to pay them the best salaries. Drugs aren't free. These huge machines like MRI's aren't cheap.

I could go on and on, but in the interests of my company I won't. If you ever want to talk about it over a beer, I could give you a lot of insight. Insurance companies let people die every day simply because they don't want to pay a good hospital as much as another company is willing to pay. And Im not talknig about a few bucks, I'm talking about 80% reimbursement versus 15% reimbursement.
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Old 11-16-2007, 02:17 PM   #4
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Quote:
Originally Posted by Cheesefood
I know many of you are going to cry BS on us and say we should treat everyone, but Dr's aren't charities. If you want the best Dr's, you have to pay them the best salaries. Drugs aren't free. These huge machines like MRI's aren't cheap.
My family has a long list of health-care professionals so I certainly won't call BS there... Doctors need to make a living just like everyone else.

[rant]I don't blame the doctors, I blame "the system"... American capitalism. Firstly, schools and universities used to operate for the purpose of furthering our understanding of the world. Increasingly, universities and schools are run like corporations (some actually ARE) with the purpose of profit. Schools now fund research in hopes of getting patent rights rather than helping the world at large. This is reflected on the STUDENT'S side - medical school is EXPENSIVE and even non-doctorate professions are insane.

Secondly, "Big Pharma" claims that they need "incentive" to research drugs and they've lobbied strongly (along with the software industry) for draconian patent laws that actually make sharing illegal. This eliminates competition, deprives the market of generics, and costs the insurance industry which passes it on to the patient.

The problem is that being "healthy" is considered a luxury, not a basic right. As long as healthcare decisions (on all levels) are made by someone who has "profit" on their list of objectives, it is the patients who will suffer.

[/rant]
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Old 11-16-2007, 02:58 PM   #5
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SWMBO is a doctor and she tells me stories all the time of people saying " I have x dollars, what can that get me?" Or "how come the insurance doesn't cover that?" Doctors have to make a living like the other poster said. They spend a LOT of money going to school to make a good living. There's a constant struggle to balance providing quality treatment and making a profit.

Healthcare is a complex subject. In one way, I take a view that if you can't afford the treatment, then you just don't get it. Yes, it will result in death but everyone dies. On the other hand, you've got to realize the humanity of the situation. Sure, I don't want my loved ones to die because the insurance company won't pay for a life saving procedure.

I think if health care professionals and businesses were given more financial breaks, perhaps the cost of healthcare could come down. Make all doctors exempt from income taxes or something and they wouldn't need to charge as much. Besides, health care providers give back to the community enough already. And don't get me started on the malpractice lawsuits.........
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Old 11-16-2007, 02:59 PM   #6
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I think the two largest problems with our current system are:

1) It is based on an insurance model yet it does not behave like one. Your car insurance for example does not pay for preventative maintenance, only for unexpected expenditures due to accidents. In the case of a driver who never has an accident, this allows the insurance company to collect large sums of money without ever paying out a dime. Health insurance does not work this way even though it is based on this model; instead, it does pay for preventative maintenance, so the insurance companies have to raise premiums and deny coverage in order to remain profitable. This brings me to my next point...

2) The insurance companies are for-profit enterprises. Does the idea that someone profits off your health make anyone else here sick? Now I am a gung-ho free market capitalist and I have no problem with most companies making a profit, but the healthcare industry shouldn't be one of them. If insurance companies were not driven to increase their profits, they would be more inclined to act in a benevolent way.

Personally I don't want the government involved in my healthcare in any way shape or form; but I believe there is a way to provide affordable healthcare to everyone by making a few adjustments to the system as it currently exists without handing it all over to Uncle Sam.
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Old 11-16-2007, 03:03 PM   #7
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While American capitalism has faults like the occasional person being denied for insurance, it has also created the best and most innovative medical system in the world. People aren't flocking to Canada and Cuba for medical procedures. Far more people are harmed by long lines, unapproved procedures that leave them with no options (at least in the States the government doesn't stop one from paying out of pocket), and the lack of innovation in socialized countries than by denied claims in the US.
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Sorry for the rant TX

 
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Old 11-16-2007, 03:03 PM   #8
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not myself, but my friend/coworker did. He tore his ACL last year and had to go through a big operation and a bunch of rehab. Now, we had (not anymore!) the kind of crazy insurance that covers exactly NOTHING until you reach your annual deductible---$2k for single users. He easily met that with the ACL tear. After you reach your deductible, it's supposed to pay for everything. Well, the doctor told him he needed more physical therapy so that it would heal properly, and he did so. Then the insurance denied his claim and put him on the hook for 4 grand. They claim it wasn't necessary. Huh? Turns out the stupid doctor didn't verify the procedure with insurance before proceeding...and now my friend is getting shafted. When a doctor says you need therapy, it's just f*cked up to have your insurance company come along and say, "ah, yeah, I don't think so".
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Old 11-16-2007, 03:08 PM   #9
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I just elected my 2008 healthcare yesterday and I chose a HDHC (high deductable $2500 family) so that I can contribute to an HSA (healthcare spending account). I'm all for this system because I've always had to pay out just UNDER the Fed/State minimums for itemized healthcare deductions. Of course FSA use would help there but I'm not contributing to a use it or lose it account. At least now I can catch a tax break on any out of pocket spending I have to do.
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Old 11-16-2007, 03:15 PM   #10
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The only case I know of personally, the woman in question went to an "alternative" practitioner for treatment of back pain because she didn't want to get her ruptured disk operated on. Ended up permanently in a wheelchair & her regular insurance refused to cover further treatment.

Other than that, everyone I know has received reasonable coverage. Which, of course, will never make 60 Minutes.

[Wish I could use my HSA for the dogs.]
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