What, exactly, does “elective” mean to a HMO? I take it to mean “That which probably won’t kill the patient or save us (the HMO) money in the long run”. But I’m pretty pissed at our sub[/sub] insurance industry. :mad:
What does it really mean?
Nose jobs, breast implants, things like that.
Things you elect to have done.
Probably also stuff like surgical sterilization, removal of noncancerous skin growths, LASIK, etc. Things you want to have done, but aren’t medically necessary.
God, I wish this was in the Pit! Those @#$%ers! The one that galls me is dental insurance…they don’t pay for ANYTHING! Oh, they say they will, but I get bills from the dentist where they’ve paid far less than what (i think) the plan says. Small print bs, I’m sure.
And furthermore, who in God’s name thinks that getting a root canal and crown is some kind of elective cosmetic procedure or something? I just paid about $1500 out of my pocket for this (my insurance co. only paid approx $500)!!! :mad:
So, miffed as I was, I called the insurance co. and asked just exactly which procedure they would fully pay for in the case of my condition, and the answer was: Extraction… They encourage patients to lose teeth! Or in the case of folks of modest means, they practically mandate it. THIS is dental insurance? Bah!
I would like to take the whole kit and kaboodle of them who made this situation the way it is and yank all their teeth out with a rusty set of pliers and no novocaine, those mealy mouthed, beady eyed f#$%s!
Yeah, good thing this ain’t the PIT. 
Hemorrhoids, they told me to sit in hot water. Laser is too expensive. They did put a rubber band on a bleeder. The doc also told me about Kotex. I’m past menopause, fer crissakes.
Hernia, they fixed because it was getting worse.
Acne, this was my granddaughter. Acne is not elective for a teen-ager. I paid for treatment. Only a couple hundred bucks, but problematic for some folks.
It’s possible that the defionition is different from country to country, but I would not agree that “elective” is refering only unneccessary luxury treatments.
When I worked in a hospital archive basically anything that could be planned was considered elective, no matter how serious. There were three broad categories:
Notfall - emergency (“Yes, it’s 3 AM, but it has to be done now.”)
Dringlich - urgent (“You stay here, the next free slot is tomorrow, 10 AM.”)
Elektiv - elective (“You will be better off after the operation, we should make an appointment with the hospital.”)
This is what I’m looking for. It’s probably close to the same in the US, I guess, but I’m annoyed at our for-profit system. I pay for the service, both through co-pay and premiums. The portion of the premium paid by my company are part of my compensation package and therefore paid bt me. Any treatment I receive costs the HMO money, unless it prevents more expensive treatment in the future.
Is the system in Germany for profit? Where does treatment that’s not neccessary, but simply for comfort and well-being fit in? Like hemorrhoids, for example.
“Elective” in insurance-companyspeak simply means “treatment that does not have to be done on an emergency or urgent [i.e. Right This Minute] basis”. IOW, if it can be scheduled at the patient’s convenience, it’s elective. If it has to be performed now, it’s considered emergent or urgent. Elective is not reflective of the patient’s condition; cancer surgeries can be performed on an elective basis. Essentially, it is a cost issue – if a surgery is done emergently or urgently, extra equipment and personnel might be required, and the insurance has to pay for those, even if the machines or personnel are only on standby. If it does not need to be done immediately, it’s basically handled routinely, and it’s not as big a deal. Don’t get caught making up a reason why your hemorrhoids have to be removed NOW; insurance companies routinely request and review medical records to determine emergent or urgent status and have been known to deny claims outright for routine procedures done urgently.
mangeorge, acne treatment is considered “cosmetic” for any age group. Doesn’t surprise me that your insurance company denied payment. I do agree that hemorrhoid removal should be covered; can your doctor make a case to your HMO?
An Arky, the reason they’re so willing to cover 100% for a tooth extraction is because it’s the cheapest and most permanent route. I’ve had root canals with crowns that are now cracked. (I grind my teeth.) An insurance company isn’t going to want to pay in excess of $1000 when a $50 extraction takes care of the problem once and for all. It is a cost issue.
Robin
If you are employed in some way, by default you are required to join a public health insurance (there are several providers, either local or more or less specific to certain professions.) Those are heavily regulated and all cover the same treatments. Your cost is dependent on your income. Those insurances cover anything medically justified, including many preventive measures. Hemorrhoids are definitely covered.
Some groups of people are not required to join this system. This refers to all self-employed persons, but also certain professions like civil servants and soldiers during their military service, because those were eligible for other government benefits. In addition to that you can opt out of the system if you earn more than a certain sum per month. Usually people who choose not to join a public health insurance join a private one instead. Those offer certain premium services (like treatment by the chief physician, single bed hospital rooms, full dental protheses…) and cost is dependent on the selected options, not income.
Personally, I am privately insured “by inheritance”, my parents were and as a student I have never worked full time, so I could choose freely.
My doctor is my HMO. Any treatment she gives me, or refers me to, costs her money. How this isn’t a conflict of interest, I don’t understand. Don’t get me wrong. She’s good, and I mostly trust her with my health. It’s just the “grey area” stuff I wonder about. To tell the truth, I haven’t really pressed on the hemorrhoid issue. I intend to.
About acne, I agree that 10-20 years ago it might have been merely cosmetic. But now most cases are pretty easily cureable, which means that very few teens suffer it, which fact singles out those who do. The treatment is quite cheap as medical proceedures go, consisting of training and prescription ointment.
in Canada (Ontario)
cosmetic - not covered
elective - medically sort of necessary, when they have time
urgent - scheduled as soon as possible (barring emergency)
emergency - right now, or tommorrow if you can live that long 