After a biopsy my mom got diagnosed with celiac disease last April, and because she wanted to feel better, she made all the dietary changes her doctor suggested.
But I know a lot of people aren’t like that, so I’m curious: can a health insurance company legally deny claims if people don’t make recommended changes to their lifestyle after getting diagnosed with treatable conditions?
I’m imagining someone who is diagnosed with celiac or diabetes not changing their diet, someone diagnosed with emphysema or COPD not quitting smoking etc; a condition that is documented that the person has and advised them of the changes to make.
I suppose the terms of the policy would control. I haven’t seen any containing language that would deny coverage for conditions caused by, or made worse by, a patient’s diet or activities.
Whose “recommendations” would this cover? Would this involve “doctor’s orders” only, or could the insurance company itself write a letter saying, “It has come to our attention that you have <condition>. To keep your insurance, you must refrain from eating <food>.”? If an insurance company could come to its own conclusions on what a person must do to improve their health, then it would become rather easy to “dump” unprofitable patients - simply give them conditions that are unreasonable, expensive, or difficult to implement, then start denying claims as soon as you can prove that they didn’t follow the “recommendations” to the letter.
"It has come to BigInsuranceCo’s attention that you have Type 3 Dihyperteneuric Tregoriosis of the left knee. Continued insurance benefits are conditioned on you taking care of yourself. Because of your condition, you must take the following steps to mitigate the condition and protect your health:
You may only drive a car that has been certified for people with your condition, currently only BMW cars have this certification.
You must take at least 3 trips a year to Sub-Saharan Africa.
You must submit DNA samples of all eight of your great-grandparents to the National Center for Disease Heritability along with ten-page biographies listing all medical conditions they had during their lives. If any are alive, they must submit to an interview with BigInsuranceCo staff.
You may not possess a round object unless it has been personally pre-inspected by a licensed physician and certified noctoparticle-free.
Thank you for your cooperation. Together, we can help you and others preserve and enhance their health."
A previous employer encouraged employees to complete a health assessment. Doing so would result in a slight discount to our insurance premiums and there was an additional discount if you took steps to improve your health (losing weight, increasing exercise, etc). So a carrot but not a stick.
Trust me, I work for health insurance and I’ve seen hundreds of different insurance policies.
They do offer carrots and sticks for various indicators of health. And if you have a chronic condition you’ll probably get a call from one of our nurses offering help managing it.
what about not treating kidney disease( besides taking blood pressure meds and diuretics to slow down progression). I do not want to go thru dialysis or transplant list. I have always wondered what will happen when it gets down to that…
If your a mentally competent adult, insurance companies can’t force you to do anything. Neither can medical professionals.
(True story, a co-worker went through a heart-lung and two kidney transplants, several bouts of leukemia related to the transplants, became diabetic, came down with transplant lung diseases that kept in a hospital for months. We called her “million dollar Mary”. The chemo for the second round of leukemia destroyed her kidney and she wasn’t a candidate for another one, so she decided to die rather than be kept alive permanently by a machine. )
You have every right to refuse this treatment. If you’re afraid people will think you are committing suicide, I can assure you that this is not the case. And you may change your mind in the meantime, should you need to make this decision.
It’s not unusual for people with ALS and similar diseases to be OK with a feeding tube or CPAP, but not a full-fledged ventilator. They have the right to make this decision, too.
I dunno about it really being a carrot. My last workplace instituted something like this, but we all noticed that our insurance premiums suspiciously went up by the same amount as the ‘discount’ for getting an assessment plus whatever ‘discount’ there was for improving your health. They called it a carrot, but it was really a stick to get you to the doctor.
I’m one of those nurses. I’m also a Certified Diabetes Educator. Mostly, folks call me when they hear they have the program, or they’re referred to me by their doctor or one of the inpatient case managers when discharged from the hospital. We try to educate the doctors that their patients with our insurance may have the disease management/wellness coaching program and we can help provide education and support. And a lot of folks appreciate it - my schedule is booked out solid for two weeks in advance. I think our program does a lot of good, but I also know it works only with folks who really WANT to make changes or learn more. I’m not for forcing people to participate - I’ve got enough folks who really do want and need to talk to me that I don’t have the time to mess with those who don’t.
If you are in an employee plan, can the insurance company “fire” you? I thought they could not even charge you a different premium from everyone else in the group, let alone drop you from coverage?
Medical advice pretty much has to come from a medical professional who has examined you; not a guy looking things up in a book and issuing form letters from the call center in Austin or somewhere. What if you had kidney disease along with diabetes type I or some other odd combination? What if the second issue was not yet diagnosed? What if you can’t perform exercises required? If they sent you a form letter that specified a diet or exercise that caused severe medical problems, they’d lose their shirt in a lawsuit.
If it was as simple as sending a form and cutting you off insurance, nobody obese would have coverage.
My understanding is that part of employer coverage means they cover everyone that you employ that wants coverage. Consequently, this means that an employer can get their rates jacked if they hire someone that needs a lot more coverage. I’ve heard tales (FOAF, I know, I know) about a small company, where one of the employees gets cancer and the insurance company triples the rate for that company’s health plan to make up for it. In large companies that’s amortized out across thousands of employees, but not so at smaller ones.
I believe PPACA limits that, since it limits rate increases, but I bet they’ll still allow ‘incentive’ to lower the company rate, which the company will then push down since they want to be paying less also.