Inconsistent insurance - Why?

Great Debates
1

:: timidly pokes head in ::
I’ve always been a little nervous about coming in here, my debating skills are nothing compared to the posts I usually find here.But I’ve been thinking about something along the same sort of lines as Smeghead’s post about insurance quite a bit lately and thought I’d ask you all what you thought.

I’ve been wondering about the contradictory policies that health insurances seem to sometimes have, and why they do things that way.Not ‘why can they’, I understand that they can do pretty well what they please.But what the reasoning behind it is.
For instance:
Six years ago I had my last child.I wanted to get my tubes tied.Insurance would happily cover prenatal care and birth costs plus allow us to put the new child on the policy once he was born.Yet they would not cover voluntary sterilisation.I can’t seem to figure out how it is more cost effective to continue to pay benefits for pregnancy, childbirth,etc. than to pay for sterilisation.Years of payouts versus one final payout.Similar to Smeg’s eye surgery.Unless of course,(and this just occured to me as I was typing) they would see all my potential children as new customers and actually look forward to me producing more people to join the policy.
Another example:
Reconstructive surgery/Cosmetic surgery - How is this decision made?If a child is born with a cleft lip, most insurance covers the repair.Even if the cleft would not have prevented the child from growing and thriving.Is that reconstructive or cosmetic?Alternately, my sister, after having both her kids by c-section has a ‘dunlop’ or abdominal apron.Essentially what that means (if dunlop doesn’t answer it for you) is that as a result of the surgical incision(meaning it wasn’t her fault) there is a good sized amount of loose skin and fat that ‘hangs’ over her abdomen.This can easily be repaired by, you guessed it, a ‘tummy tuck’ or abdominoplasty.But this kind of surgery is considered ‘cosmetic’.Both conditions, if not actual health risks, can cause the person to feel ‘freakish’ or have self esteem issues.If this is the criteria for the cleft lip repair, why isn’t that criteria also used to judge the nessicity(sp) of the adominoplasty?
One more:
Prescriptions - I’m sure this one could be a whole debate by itself but I thought I’d throw it in, too.Wellbutrin(sp) versus Zyban.If I remember rightly, these are the same drug.Why cover one for one use and not the other for an alternate use?I can’t remember the specific names but I believe that there are more examples like this i.e. same drug, different uses, that are covered in one instance but not in the other.I’ve heard more than once the advice to “Ask your doctor to prescribe you Drug X for depression instead of for smoking cessation, insurance will cover it for that.”.Do the insurance companies not know that this happens?And wouldn’t it be easier on everyone involved to just cover Drug X for all its legal, FDA approved uses?

my opinion on this, for all it’s worth, is that insurance companies should be consistent with their policies.If Drug X is actually Chemical A and Drug Z is Chemical A as well, I believe they should either cover all FDA approved uses of Chemical A under whatever name, or cover none.If Surgery A is considered ‘reconstructive’ based on the possible emotional trauma the afflicted may sustain from living with it, I think that Surgery B should also be subject to the same criteria.I can see right now that someone may say “What about boob jobs?”.Well, the best I can do is say that in cases such as mastectomy, the cosmetic creation of a breast should fall under such criteria to be considered ‘reconstructive’.But “Janie cries at night because her sister is better endowed than her…” should not.I’m thinking the reasoning there is obvious.

I’m hoping I’ve worded this in such a way as to make it a ‘Debate’ instead of IMHO material.I have read much of what has been discussed here in GD and look forward to having the same insight and intellect applied to this subject.Otherwise I will humbly accept banishment to IMHO.

So I guess the actual question here is: Why do insurance companies have contradictory policies and why is that acceptable?Again, let me say that I do understand how it is possible that they are as they are.It is the why questions that I’d like to see addressed.

Thank you for taking the time to read this.

2

How about this, three bunny mama: My gf’s insurance company is more than willing to pay all the associated costs of pregnancy, but refuses to pay for birth control prescriptions. How short-sighted is that?

3

The first scenario, and that of Necros, have been covered in another thread.

Insurance companies will frequently feel that they must cover medical conditions, but not lifestyle decisions to have medical treatment.

An even more extreme example of this is that certain insurance companies will cover the cost of expensive treatment to cure the underlying cause of certain types of infertility, but not cover simpler, cheaper methods of becoming pregnant without treating the cause.

4

That’s interesting that some insurance won’t cover birth control, since some covers Viagra.

5

Let me take a stab at explaining the birth control vs. Viagra argument. Traditionally, any insurance you buy, whether for medical expenses, car repair expenses, home repair expenses, or risks of sailing ships on the high seas, is for the purpose of not exposing you to large, unpredictable expenses.

If you can either afford something, or predict it, then it makes no sense to get insurance. For example, you don’t take out insurance to pay for a new battery for your car, because you can afford to accept that risk yourself. And you don’t get insurance to pay for new tires when yours are worn out, becuase that is pretty predictable.

Contraceptives clearly fall into the category of something I can predict and afford. A flexible insurer could agree to cover that, but they’d have to charge more for the policy than it would cost for the contraceptives. So I as a smart consumer elect to pay for it myself.

But I do want a policy that covers costs to treat medical problems, and as Bob Dole has informed us, “ED” is a medical problem, so they will cover it.

6

There are “lifestyle” or philosophical reasons for some insurance companies not covering certain items, but not for the most part. Take it from me: virtually all coverage decisions are actuarial/cost-benefit decisions. Put simply, the most profitable path is the preferable one for insurance companies, to the extent they can get away with it.

To use the birth control example: If the company determines that enough people who are refused birth control will buy it themselves anyway, it’s profitable not to cover it–i.e., the pregnancy costs for the few who won’t buy contraceptives (if not covered) is the lesser expense.

I have not found insurance companies to be terribly troubled by any factors other than those which most favorably impact the bottom line. To the extent that different companies have different coverage policies, you can attribute that to different premiums, different methods of determining profitability, different customer bases, or a host of other things.

But they’re all trying to make the most $$$ they can, and troubling ethical concerns dissipate like the morning fog whenever someone makes a convincing business case.

7

Thank you all for posting.I appreciate you taking the time to respond.

IzzyR - Sorry about the repeat; I really should have done a search first.Thanks for responding anyway.
I’ve now gone back and read Falcon’s thread Paying for birth control…Catholics exempt? and there are some interesting arguments both for and against insurers providing birth control.And Izzy, you are right on it with your example of insurers paying for one treatment when another would do just as well and be cheaper in the long run, if I’m understanding you correctly.

But to be honest, whether insurance should or should not cover birth control isn’t really what I meant.I only used that particular example because I felt like it best illustrated what I feel to be contradictory policy.I know how hot the issue of insured birth control/pregnancy can get.It wasn’t really my intention to start a debate on just that issue.I was really looking at the broader view, more like insurance ‘policies’ in general and how contradictive they seem to be.
I’m thinking that perhaps I didn’t word the OP as clearly as I would have liked.Instead of"Why do insurance companies have contradictory policies?" I think maybe this is more to the point:
Why should insurance cover X but not Y when they are essentially the same?Why should insurance provide for the treatment of the symptom, but not the cure?Who, if anyone, benefits from this?

Maybe a better example would have been tonsilectomy.I know insurance covers this, but let’s pretend it doesn’t for a moment.If a person had recurring tonsilitis, wouldn’t it be less expensive to simply remove the tonsils rather than treat the infections for years and years?
And if our imaginary insurance company covered treatment for the infection but not the tonsilectomy that just wouldn’t make sense(to me at least).But I’m pretty confident in saying that there are more ailments that insurance provides longterm treatment for(like antibiotics, prenatal care, etc.) but will not cover an outright ‘cure’ (like getting the tonsils out or getting sterilised).
Its been pretty well established that insurance wishes to provide the minimum nessecary care at the lowest cost possible.Following this logic it would seem that if by providing Treatment X once, you would not ever have to provide Treatment Y, that Treatment X would in fact be the most cost efficient.

Covering Drug X but not Drug Y when they are the same medication just doesn’t make sense to me.Covering years and years of Treatment Y at $1000.00 per year but not covering Treatment X at a one time cost of $1000.00 seems foolish.Or providing one treatment because it is considered ‘reconstructive’ but not covering another very similar treatment because its considered ‘cosmetic’ doesn’t add up quite right.And its these kinds of contradictions that I was kinda looking for thoughts on.
Shouldn’t insurance companies that provide X also have to provide Y when Y is no more expensive or even cheaper than X?And as effective or more effective in the long run?If not, then why?
If an insurer covers Drug X for treatment of cooties and the FDA approves the use of Drug X for treatment of hay fever, shouldn’t insurers have to cover Drug X for hayfever even if it is differently named?If not, then why?
Is the decision to cover X made soley on a cost efficiency basis?If that is the case, why do they decide to go the more expensive route?Otherwise there must be some other criteria used when deciding what to cover and what not to.
And if cost were the deciding factor, then I see no reason why Drug X and Drug Y(both being the same drug, just differently named) cannot both be covered.But they aren’t so there must be more to it than that.
I can see no possible benefit to the insurer or to those paying for the coverage by doing these kind of things.

And if I’ve now confused things beyond the point of understanding, please feel free to ignore this. This is my first ‘Debate’ and I’m just grateful that I haven’t been eaten alive yet. :wink:
Thank you all again for responding.

8

I have no idea where that big blank space came from.

Bob,
I didn’t see your post before I responded. I agree completely that cost is a major deciding factor.It would just be bad business for insurance companies to not try to cut costs.
But how does that explain the Wellbutrin/Zyban bit?In what way is one more expensive than the other?As far as I know 10 milligrams of Wellbutrin should cost as much as 10 milligrams of Zyban since it is the same drug.If I’m wrong about that somebody please let me know before I really make a fool of my self.
If there is no difference in price, why isn’t it covered?

9

We had a separate thread devoted to the Birth Control v. Viagra providing by Insurance companies.

Concerning the Welbutrin v. Zyban complaint, my old insurance company covered NEITHER, but only because people kept having their doctors write them Welbutrin perscriptions for quitting smoking, and the insurance company got sick of it.

On top of that, my company changed insurance companies two weeks after I purchased my one refill of Zyban. The old insurance company did not cover the Zyban under its prescription plan, so I had to pay full price ($100 each), but they did take a claim from me and take it off my deductable.

My new insurance company DID allow Zyban under its prescription plan, which meant I would only have to pay $20 for each one.

If I would have quit a couple of months later, it would have been covered. :mad:

Yer pal,
Satan

I HAVE BEEN SMOKE-FREE FOR:
Three months, two weeks, five days, 22 hours, 34 minutes and 47 seconds.
4437 cigarettes not smoked, saving $554.70.
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10

There may be no difference in the cost of prescribing it, but the insurance provider may have determined that refusing it on one grounds is cost effective AND consistent with their coverage policy, the other not. Any inconsistencies not associated with profitability won’t trouble them greatly.

For example, say the provider determines that the rate at which Zyban actually facilitates quitting is pretty bad (it’s better than cold turkey, but still very low, I believe). They’ll determine what the cost of providing coverage is, then compare it to the cost of not providing coverage (hey, most of those guys are still going to be smoking anyway!). Last step: look for some justification in not providing coverage that will not send most of their customers scurrying elsewhere.

Its use as an antidepressant may not lead them to this same conclusion, so they’ll cover it–it’s that simple in most cases. And the fact that it costs the same amount to prescribe in either case isn’t relevant and won’t make them lose a minute of sleep. If providing coverage maximizes profit (i.e., you keep customers and revenue at a rate that exceeds expense), they’ll do it. If NOT providing coverage maximizes profit…you get the idea. May not be terribly ethical, but that’s the reality.

11

My insurance wouldn’t cover birth control or sterilization, but would cover pregnancy and abortion! They just now started covering sterilization. What made them change their mind? I have no idea.