CBS has a good storyline about medical insurance and this is just one of the stories featured. This so much reminds me of the recent Blue Cross settlement here in California where the carrier did settle. This is scary to think that when someone is in dire need of medical assistance that when it comes down to billing, the "bean counters" are put to work to scrub and research the data bases looking for any type of mere scan of a chance to deny paying services.
Why did this potential record take 3 years to surface? Why did the insurance company not question this 3 years ago? I'm sure they willingly collected his premium payments for the last 3 years as well. This could happen to anyone.
I am a programmer and create data bases and they are helpful and informative and lead to better healthcare, however, some tend to forget that this is still the "people" business and that human bodies are not the same as data and statistics and we do not all fit into "tables" and our ultimate healthcare is not just the matter of another "structured query" to determine whether or not our body justifies claim payments based on the criteria returned. People have afflictions and illnesses due to no fault of their own - they are born with many of them!
If we continue with the current system, then something has to be done to create an "assigned risk" category and pro-rate those folks and assign them to insurance companies for coverage. The car insurance business has assigned risks, so I ask, why can't something along this line be accomplished with medical insurance? Myself, I would much rather see pro-active direction with the insurers rather than the government make the decision for everyone as to what will occur, but if pro-activity is not taken, then the latter will more than likely be the ultimate decision for all.
When a member of the Los Angeles Insurance Commission is denied coverage, you have to ask, where does that leave the rest of us????? BD (see the related story below)
Walking along a stretch of road last summer, 54-year-old Tod Smith felt an intense burning in his chest and tightness in his arm — signs of a heart attack he never saw coming.
"I was in good health," Smith said. "No major health problems or conditions."
For Smith, an illustrator of children's books, his heart attack was the first shock. The second: more than $40,000 in medical bills his insurance company refused to cover — after he figured the company, Assurant, would pay.
"I certainly figured that a heart attack was a catastrophic event. So I figured I was covered," Smith said.
A two-month CBS News investigation of the individual insurance market found that Smith's experience was far from unique. Because it was expensive, his claim was investigated for fraud by Assurant Health, his insurance company.
After examining his medical records, the company refused to pay based on a 3-year old-reference to an "angina episode." Assurant said those words proved his condition was pre-existing, despite the fact that follow-up tests in the same file diagnose his "episode" as a case of acid reflux and ruled out a heart condition.
Assurant refused to discuss its denials of claims on camera, but it issued a statement saying it continually evaluates its claims process "to ensure it is fair, equitable and consistent with state laws and industry standards."
Source: When Health Coverage Doesn't Hold Up, CBS News Investigates How Individual Health Insurance Providers Can Deny Big Claims - CBS News
Related story: http://www.cbsnews.com/stories/2007/05/23/cbsnews_investigates/main2843007.shtml
MEMBER OF CALIFORNIA INSURANCE COMMISSION DENIED COVERAGE
Scott Svonkin, an active 41-year-old, never thought he'd be one of them.
"Pacificare rejected me because I'm an expectant father. Blue Shield rejected me because I got a spider bite. And then this one rejected me because of asthma," Svonkin said.
Not for Svonkin. Ironically, he's a member of Los Angeles County's Insurance Commission.
"I never imagined it would be so hard to get health care," Svonkin said. "It's not a matter (that) I can't afford it. It's a matter that they won't give it to me at any price."
Insurers find all that information — and much more — in a massive, little-known data base called the MIB, or Medical Information Bureau. Insurers have even been known to question "friends and neighbors" about "morality and lifestyle" — using all of this information to decide who they will cover and who they won't.
"They can check your morals and your lifestyle?" asks Keteyian.
"Exactly," says Liang. "And they are going to judge you on this."
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