Out-of-Pocket Maximums Explained
In the recent film “Sicko” Michael Moore points out the tragedies of several Americans who actually had health insurance and yet were denied coverage for treatments by their insurance companies. Recent studies have shown that the experiences of those in the film are far from unique. While there are 47 million Americas without access to affordable medical insurance coverage, it seems that there is also a myriad number of Americans with health insurance who are fighting with those very health insurance companies over denial of coverage.
Case in point: Kansas City resident Julia Slaven. Julia had been battling cancer of her immune system. Her health insurance carrier would not pay for cover stem-cell transplant procedure even though her doctors insisted it was a necessary and life saving procedure. The insurance company deemed it “experimental or investigational.”
Slaven, 55, decided to take her fight to the streets .She staged a protest including her and dozens of friends and relatives at the offices of her insurance company’s offices. That very same day, she received notification in the mail that said the company had relented. It would now cover the transplant, not because of her objection mind you but because they had her case reviewed by three independent physicians. Slaven said it made her feel good that they changed their minds so quickly. She had the transplant several weeks after that and she said you just need to stand up an fight for yourself.
While Julia tactics may have been a little extreme she is far from alone in her struggle. Americans on an ever-increasing scale are fighting with their health insurance plans over denials prescription medications or doctor recommend treatments. These patients and their families’ battle through a complicated corporate bureaucracy and a tangled web of paperwork to try to get the decision of a health insurance provider reversed.
Julia’s experience is typical of the reason for most health insurance denials. Healthcare plans often label a new medication or treatment as “experimental” to warrant their decision to negate a claim. But medical professionals say it is very difficult to define when a procedure is experimental. Patient advocates say it is a definition that needs to be set by doctors, not heath insurance companies. Medical practices and access to care vary from state to state across the country. A procedure that has been performed many times with great success in New York or Boston, may still be considered experimental in a place like Kansas City, where it has been preformed far less, or maybe not at all.
So how does a health insurance company decide what to cover? Doctors say it is driven by profits and not medical need. Julia’s doctors claimed “The insurance companies look at the cost and needed a reason to not pay the claim, and so they rubber stamp it as experimental.”
On the other hand the insurance industry says there is no mystery or conspiracy behind coverage decisions. A spokesman for the largest health insurance trade association America’s Health Insurance Plans said,
“Coverage is driven by the medical evidence that something works and the ability of the employer and consumer to have that provided in a benefit package.”Still patients like Julia say, if you are denied coverage, don’t just take it - stand up and fight.