And further, how is a diagnosis of breast cancer indicative of possible fraud? Does breast cancer afflict the dishonest more than say, colon cancer?
Actually they have access to your medical history for your whole life. They will go through them and look for some reason to not pay. It could be you did not mention you took a medicine when you were a teenager . They can declare it fraud and kick you out. The head of HHS told them to knock it off because when the Health Care Bill kicks in ,that would be illegal. The woman who runs Wellpoint made a 9 million dollar salary and got a lot of stock. She is only interested in making more money. Providing health care for their customers is something they fight against. It is a stupid system.
Breast Cancer patients are not more fraudulent than others who get sick. But Wellpoint has an algorithm that picks them out. They may have one for other diseases. But the breast cancer one has come out.
Some people willingly lie on their application in an attempt to qualify for (or reduce the cost of) insurance (like saying they don’t smoke or drink when they only have a couple now and then). The onus is then on the company to evaluate if the claimant is fraudulent and deny the policy if they are. What sucks is that the company doesn’t have to do it, and can accept your premiums for your entire life. It makes the most sense financially to let you lie on your application, pay your premiums, and then review your case when you try to make a claim.
The auto insurance industry has been doing this for ever. If you lie and claim you don’t drive your car to work, or that your work is 5 miles away instead of 10, they will happily issue a policy and collect your premiums.
When you get in an accident 7 miles on your way to work and make a claim, your insurance agency is going to drop your policy (or not pay out) because YOU were fraudulent. Now that you want money, they have an interest in verifying your policy.
The health care legislation tried to prevent insurance companies from doing that, in order to stop valid policies from being dropped. But included in that is the inability to drop invalid policies.
If the insurance industry can’t drop invalid policies, they open the gates wide to fraudulent applications. What other incentive is there to not lie even a little on your policy (maybe you forgot to mention your great aunt had breast cancer or that you currently have a lump you’re worried about)?
Following this through: if we flip the power basis, the insurance companies will have to pay out first, then wait for the third party review, then try to RECOVER the money they paid out.
But that money is gone, how are you going to get money back from someone that just spent $250,000 on a bone marrow transplant? At least with a car you can repo the car.
Does it seem right to prevent an insurance company from evaluating fraudulent claims?
eta: I don’t why they choose breast cancer. WE also don’t know if it was just breast cancer. As far as I can tell, they have an automated trigger when someone files an expensive claim. Perhaps breast cancer patients have policies that are easier to drop.
for the record, i believe the IRS has automatic triggers when looking for who to audit.
eta further: I would suspect they have a system for evaluating policies that is in proportion to cost of treatment.
Yes, most insurance in the US is provided by employers under group plans. And employers can and do switch insurance companies. My old employer switched medical, dental, and vision providers 4 or 5 times in the 14 years I worked there.
But the insurance company can always decide that a particular case wasn’t covered. Especially if they can “prove fraud” on the part of an employee.
Prov?. They can refuse to pay and you have to go to court to force them to pay. If you can not afford it, or are too sick to fight them, you lose. They get out of paying. They win. They do not have to pay while the case is in dispute. The system is set up for them to win.
That is why the “prove fraud” was in quotations. They don’t have to prove anything, just claim it.
Well, for me, the entire issue is moot, since I oppose the entire concept of healthcare financial administration being carried out on a for-profit basis.
However, the current system beng what we have to deal with, I’ll put forward this objection:
What doesn’t seem right is permitting them to delay evaluating fraudulent applications. When I enter into a contract with another party, I am responsible for my own due diligence; I feel I also have the right to expect that my counterpart has also fulfilled his own due diligence responsibilities.
To the extent that I’m comfortable with having health insurance companies operate at all, I’m comfortable with making them do their due diligence prior to entering into a contract, and including the cost of that due diligence in their premiums. Or making an initiation fee an option for the client to choose, which would cover that cost. Similar to a title search prior to a home sale.
But that’s not entirely the answer we need.
I’m under the impression that as a general rule group plans don’t drop or deny coverage. The risk of losing the overall contract with the employer is too large compared to one specific case. Is this true?
We really need an answer to that for other things to be discussed.
Consider it from any insurance company’s POV: They offer you two policies, one if you smoke and one if you don’t. If YOU chose to lie in order to get the cheaper policy, that is fraud, and your fault, not there’s. They can choose to evaluate (like a swab test) or take your word for it. You have entered into the fraudulent contract voluntarily. As far as they know they are taking your money legitimately, and you are giving your money because you told the truth. When you want them to obligate the contract why should they do so if you lied? They assumed that since you signed a contract, and were willing to give them money, that of course you told the truth.
What this part of the discussion should teach us is that having insurance pay for health care is fucking retarded.
Health insurance companies are acting EXACTLY the way an insurance company is supposed to act. Any other behaviour would be irresponsible as a business, and result in their bankruptcy.
Your auto insurance provider is going to do everything it can to avoid paying out a large settlement. If you lied on your application, they are NOT going to pay out.
If your home owners insurance requires you to have a working smoke detector, they are going to check to see if it’s working AFTER you want a claim. If it’s not working, they are not going to pay.
That’s insurance, it’s how it works. We shouldn’t be surprised that health insurance providers are acting this way.
When I heard that they had an automated system for breast cancer claims, I actually said, “well duh, paying for cancer is expensive.” Ditto for AIDS. I forget the current numbers, but it’s something like $100,000 a year for the rest of their life. So as an insurance provider, it is your obligation to avoid as many AIDS patients as you can.
It’s not cruel, it’s how the system is supposed to work.
You have just made an excellent argument for single payer, government health insurance.
Yes I know, and it’s not the first time I’ve said it. Nor the first time it’s fallen on many deaf ears.
that’s what he’s been doing all along. You must have missed this little exchange:
So that’s OK with you? Is it still stealing to tax you to pay for socialized health care for everyone?
Perfectly okay. Pretty much everyone in the US is aware of the fact that private health insurance costs more than a group based plan. And a group based policy gets cheaper the larger the group. UHC maximizes that by including everyone making the largest group possible. It just makes proper economic sense. Not common sense mind you, it makes economic and fiscal sense. My individual cost goes down so much that I’m okay if a few people get service for free as a side effect.
See the way it includes me in the equation? It even includes you. In fact, it includes everyone! Having to pay for someone else’s health insurance is theft. Having to pay for the bullshit system described in this OP that I’m not eligible is theft.
Create a system that includes me and I’m happy to pay for it. Create a system where I team up with other people to bring my costs down and I’m even happier.
If I had to pay for a private teacher for my kid it would cost a fortune. So I could team up with a bunch of other parents and bring my cost down significantly. There is a point where if a couple kids sit in the classroom for free I’m happy to let them benefit. Just don’t make me pay for a school system that my kids can’t go to.
My previous post was a bit wordy so I wanted to point this out again. We’re not talking about common sense, this is much higher brain function. This is deeper into the crevasse type thinking. This is a tactical retreat to gain higher ground and flanking potential. I have about 8 more of these but I’ll leave it at 3.
It’s not my sense that people are particularly miffed about the insurance companies disallowing benefits to patients who knowingly defrauded their way into a policy. It’s also not my sense that a particularly large percentage of patients who were treated that way can be said to have knowingly defrauded their way into their policies.
Would you care to disabuse me, with some cites?
No, I have no cites. I have no idea how many people defraud their insurance (intentionally or otherwise). I also don’t have a lot of faith in humanity, so my gut tells me it’s high. I would peg it at about the same number of people that make errors on their tax return (intentionally or otherwise).
But the previous point remains: should insurances companies be allowed to investigate clients for fraud?
That was the legislation that insurance lobbyists fought to have removed from the bill.
Not after clients have been diagnosed with illnesses that are supposed to be covered under their policy. The insurance company has a responsibility to investigate fraud by all of their policy holders, not just the ones who have legitimate claims. If they only feign interest when it will save them big money, I believe they should be not be able to cut people off because of some minor infraction of the policy from years earlier. They had their chance, they didn’t do their due diligence. Tough shit. Maybe that will teach them a lesson.
Fine, but now you’ll have to answer these questions three:
- are you willing to do that to all insurance companies?
- what level of fraud are you willing to tolerate
- crap i forgot the third, oh ya, is there a time frame you’d like to propose?
- what lesson are we teaching? Is this all about punishing bad behaviour?
Well, its at least partly that, but also that if we hang a few, it will encourage the others and inspire them to virtue.