Medical Insurance Industry - evil or just uncaring?

[PatGund]

A friend of mine down in California has been fighting for well over two years with her insurance carrier (GPA, AMM, and Regence BlueShield of California) to treat pressure and swelling in the cranium, as well as a large ovarian cyst. She was a programmer making good money, but is now on disability due to her conditions and is scrambling to support herself and her daughter.

The go around has been this:

Doctor prescribes and recommends a particular type of treatment, does referral to neurologist.

She makes appointment with neurologist.

Neurologist confirms treatment needed, makes arrangements to have surgery done.

Insurance company REJECTS claim, demands she goes to another neurologist.

Second neurologist punts, passes it back to original doctor.

Insurance company denies surgery.

Friend goes back to doctor, whole process starts over.

In late May the State of California ruled AGAINST her insurance carrier and told them they HAD to authorize the treatments the doctors recommended for her. The insurance carrier actually ignored the state and denied her again.

To make matters worse, the pressure in her skull has put pressure on her optic nerves, causing her to lose her vision. Yesterday she saw a neuro-ophthalmologist. She's lost 85% and 87% of her vision since April, meaning they're going to have to do surgery to relieve the pressure on the optic nerve to save what's left. There's less than a 5% chance she'll ever regain the vision she lost - and the neuro-ophthalmologist said if the insurance carrier had allowed her to come to him earlier, he could have saved her vision completely.

So, thanks to the utter incompedence, greed, and banality of GPA, AMM, and Regence BlueShield of California, my friend is in constant pain, unable to work, worried she won't be around to raise her daughter, and has now lost most of her vision. While the bean-counters openly flout the State of California in denial of services.

Personally, I hope she sues the asshats so their next five incarnations are paying restitution

[Warpy]

1. Unnecessary blindness is a very big deal

and she does need to sue them.

It's a shame it has to get this far, that we pay and pay and then have to sue the bastards to deliver what they promised us for all our money.

Blue Cross needs to be put out of business, they've become among the worst of the worst.

In the meantime, to anyone who finds themselves in this sort of insurance company runaround, get the care and then sue the motherfuckers. Don't allow yourself to become permanently disabled first.

That's advice I gave to a relative. She's alive and she won.

[sui generis]

18. as opposed to necessary blindness

:P

Seriously though, agree with you that anyone in that situation needs to NOT WAIT to get treatment. You only have one body, and you better be a quarterback for it, not a scorekeeper.

You can't sue the bastards unless you're still alive to do it, and winning a lawsuit on permanent disability is hardly worth struggling to stay alive to do it.

[Warpy]

29. As opposed to preventable blindness.

[Glorfindel]

2. How horrible - we have the worst of all possible health care systems

It's RATIONED BY ABILITY TO PAY, which is sickening. Your friend could have had better luck with a witch doctor in Haiti, chanting spells and burning chicken feathers. :sarcasm:

I agree with you; I hope she can find a lawyer who can send all the bean-counters involved to the poor house forever.

[Marrah_G]

3. It is a corrupt system

The system is broken.

HOWEVER: It is a system, it is a business, a market. It is not capable of caring or not caring, of being evil or being good.

Individuals within the business place may be caring or uncaring, but a business is not a live entity. It is a product of the individuals who are part of it.

[Jackpine Radical]

5. Nevertheless, based on its behavior, the modal corporate "person"

is a psychopath.

[Skidmore]

6. Businesses are made up of people.

I really loathe that perennial argument that the market/business is incapable of caring or being evil or good. If there is an expectation that an industry/business be a good corporate citizen conduct themselves in a market market according to established rules of fairness, then there is systemic "conscious" built in. The problem now is that those regulatory structures have been decimated over the past twenty years. Hence, the current "Wild West" mentality when it comes to commercial activities.

[Marrah_G]

8. Did you finish reading my post?

It is the people running them that are caring or uncaring, and among those people there are varying degrees.

It's like labeling a car good or evil. The business is a vehicle which is driven by humans.

[Skidmore]

9. Under established law, a business or corporation has personhood

and is treated as such in the courts. Why not the expectation that the entity conduct itself as a person? Regulation needs to be reinstated.

[Marrah_G]

14. I understand how you are looking at this.

I just see things from a different point of view. I tend to be a bit literal.

I agree strenuously with regulation. I think people who are running these companies need rules and consequences when it comes to their impact on our communities.

[notesdev]

21. Most of the business has no valid reason to exist

HMOs by and large are middlemen who add costs and other burdens but no value to medical care. Its interests are wholly aligned against the best interests of both patients and service providers. Take them and the money they soak up out of the equation, and insurance would be needed only for a relative few; routine medical care would be easily payable out of pocket for all but the poorest of the poor.

[Marrah_G]

23. I agree with you- I despise HMOs- We need single payer socialized medicine like Canada.

[Edweird]

30. A car is an inanimate object made of steel and plastic. A corporation is made of people.

You are allowing some sick degenerate sadist to hide in the relative anonymity of the "crowd" and be shielded by some meaningless "policy".
A car has no thought.
Some bastard decided to deny.
There is a world of difference.

[Occulus]

24. Loathe the truth all you like. It's still true.

Business, in the main, is uncaring, and often sociopathic. This can be traced directly to the corporate legal requirement to benefit the shareholders. Shareholders can sue if the company is too nice, either to its customers or its employees (as Ford himself discovered, back in the day).

I'm getting tired of people repeatin the line that businesses are made up of people. Of course they are made up of people- what else would be the case? However, what you need to understand is, once those people walk through their corporate entrances, they are not people, bound by conscience (I believe that's what you meant when you said 'conscious'), but rather cogs in a virtual machine: the corporate legal framework.

So, yes, corporations are evil and untrustworthy by default. They are inherently sociopathic entities and we really need to strip them of their personhood entirely.

"If there is an expectation that an industry/business be a good corporate citizen conduct themselves in a market market according to established rules of fairness,"

I don't know where you got the idea that such a thing exists, but it simply doesn't. Fairnedd and being a good citizen do not enter into the equation. Don't bother bringing up the laws, either, because they are meaningless when fines and penalties are factored in as a cost of doing business.

What we need is a corporate death penalty, extending to the ability of board members to hold board memberships in the US, period. The Enron board of directors, for example, ought to be legally forbidden from being a board member or owning stock shares in any corporation ever again.

[Jackpine Radical]

4. Evil OR uncaring? Why do I have to make a choice?

It's just another example of corporate psychopathic behavior, motivated entirely by self-interest. Insurance companies are among the most amoral of corporations, which are already an amoral bunch.

[ellacott]

7. This is why Universal Health Coverage won't be the only answer

No one is talking about reforms to the insurance industry.

[Cleita]

13. The only reform for the insurance industry is to get them out of the

health insurance industry altogether. Insuring the young and healthy and not those who actually need health care means this is a parasitic industry that only siphons dollars to profits that are needed for actual health care.

[ellacott]

15. Yes, very true

They get away with so much because they aren't challenged. I have to deal with them on a regulr basis and their goal is to deny as much as possible. They get away with this because a lot of health care providers don't challenge them.

[PatGund]

17. In this case...

They were challenged, the State of California told them "No, you screwed up", and she got a copy of the form from the state ORDERING the insurance company to authorize the treatments needed, and the insurance company ignored the state and denied her again anyway.

[ellacott]

22. This is awful

I hope she gets some resolution and is able to sue them.

[Cleita]

10. I hope she sues them too, because it will be the only way she will have a

chance of getting the medical treatment she needs. As to your original question, insurance companies should not be insuring health. Insurance by it's very nature is to insure you in case of a catastrophe. Like you get car insurance in case you get into an accident. You don't plan on getting into an accident and if you drive carefully, the odds are you never will except under unusual circumstances. The insurance company gambles on this so that they pay very little out in claims. Health care on the other hand is something that we will need more and more as we age. For insurance companies to remain profitable, they have to insure the young and healthy and then cut them loose when they start becoming a liability. Health insurance is not for those who need health care. I think it should be outlawed for insurers to be in the health business, so that we can move towards a health care plan that provides health care for the sick or a single payer universal health plan.

[The Stranger]

26. Forget it -- even if you could assert a cause of action, you would never collect.

They have done away with civil litigants' rights while the sheeple slumber.

[sshan2525]

11. Not evil....

for profit. Often equals the same thing, though.

[WillowTree]

12. Are you sure it's Regence Blue Shield?

As far as I know, Regence Blue Shield only does business in Oregon, Utah, Idaho and Washington state. And Regence is one of the not-for-profit Blues.

Blue Cross/Blue Shield of California is a separate company and for-profit, owned by WellPoint, which is also the parent company of UniCare, the worst of the worst in my opinion. If she's dealing with BC/BS of California, I'd recommend a good attorney, and fast. That's all they understand and they don't even understand that very well.

[PatGund]

16. It's BC/BS of Calfornia

Though I thought she said they changed the name down in California as well to Regence Blue Shield

[RadiationTherapy]

19. Get over it. They are turning a profit which is the only consideration.

We are a profit driven, capitalist society. Profit at all costs. Get over it or we must change the basic premise of this country's economy.

[Wcross]

20. FOR PROFIT.

They are in the business to make money. The less money spent on claims the more money they make.

[The Stranger]

25. Evil. Wake up.

[sui generis]

27. Fact of the matter is (applies to all insurance everywhere)

Insurance is the original racketeering scam.

While well regulated insurance does say you have a pool of likely casualty and chronic casualty that has to be offset by the premiums you charge and underwritten by reinsurance schemes (the money game), in order to get enough private investors to drive cash basis you have to show that your "business" is 1. making a profit, and 2. growing that profit over time. Here starts the problem.

There are only two ways of doing that 1. reduce your accommodated costs 2. reduce your risk.

The easiest way is to never have to pay on a policy, hence we're back to racketeering, or charging for a service you don't deliver. So insurance companies continually adjust risk groups to have groups that have the least probability of having significant claims or else that distribute risk in such a way that a particular group's claims do not exceed its adjusted premiums. Because regulatory restrictions are different in different states, the insurance industry takes that into account as well in deciding how it handles certain potential costs. It may have looked at the lawsuit cap on your friend's potential lawsuit and compared that to paying out for what they "predict" may be a cost layout that is greater than just paying the settlement, provided she survives and sues (and there's a reliable statistic for that too).

There are difficult to explain but reliable periodic cycles in all insurance outfits that factor in as well, so they try to make up in advance for the lean "7th" year cycle and other chaotic system math.

They don't "care" or "not care" about anything except margin. Everything else is a revenue stream when viewed from the strategic perspective of a Harvard MBA, and very little of that perspective gives any credence to good works or pro bono as anything but good PR, designed to sucker in more people through viral marketing.

You are the living person here. Whatever the law says, you have a GREATER right to survive reasonable harm using reasonable means, both preventative and tactical, than a company has to their ureasonable expectation of profit.

Once the government established lawsuit caps on total comp in your state and at the federal level, they placed the civil "rights" of an enterprise as higher than the human rights of an individual. This really is the America we live in. A constitution to protect corporations from evil individuals. It's not science fiction - it's here, and your friend is seeing the result first hand.

If the cap is 400K, and your friend's treatments cost 300K, her lawyer costs another 150K and the punitive award is millions of dollars, the company only has to pay 400K to satisfy settlement, most likely leaving your friend both blind AND broke.

And exactly who is it that thinks California is a liberal bastion of progressiveness? They have some of the most draconian legislation out there for companies to hide behind.

[mvd]

28. It's a symptom of the evil of a system that allows..

health care to be for profit. Capitalism that interferes with what I see as a basic human right (health care) is evil.