Revised: April 17, 2009 @ 1:30pm

Recently, a patient who is also a practicing physician came to me with a letter from her insurance company. As I read it, I began to question the validity of the statement. The letter, which contained the advice of the company’s medical consultant, denied her claim for compensation, even though she had paid premiums over the course of twenty years – and had never made any claims previously. She was seeking my advice on how to respond to this dilemma.

Philosophically, I have never been a friend of the insurance systems in place and will generalize by stating that they operate in a similar fashion throughout the world. Indeed, many of them are multi-nationals for obvious reasons.

Salesmen extol the virtues of their “comprehensive coverage”, in order to obtain substantial commissions. No one ever reads the policies that cover numerous pages of small print, that cannot be read nor are intended to be read. The insurance company then puts the premiums in the till and invests the proceeds to pay for their overhead, enhance shareholder value (bottom line) and to possibly even provide coverage for those who ante up the premiums. Reality indicates that management takes care of management first and basically “to hell” with everyone else. With regard to the payment of claims submitted, the almost invariable response is, “we do not cover this: read the fine print!” – which I would presume eliminates over 90% of supplicants.

As the prevailing economic crisis has revealed, insurance companies through their investment subsidiaries have engaged in extensive speculation in derivative and other unsound financial products – in other words, they are gambling with the money received from premiums and concomitantly reneging on their obligations. This completely refutes the foundation on which insurance was based. Moreover, this particular case highlights the egregious method of abuse practiced by the companies, unchecked by the so-called regulatory bodies, which consist largely of governments and their bloated bureaucracies. It should be noted that many of the biggest contributors to political campaigns of all stripes are insurance companies and those who provide financial services.

Based on good evidence, it appears that money paid to insurers to provide for the payment of claims is in reality used to enhance the compensation of managers, as a secondary priority to increase share value and both last and least, to provide coverage for those who pay the premiums, i.e. the would-be primary beneficiaries. To me, this appears to be totally wrong – if not an outright form of fraudulent activity.

The letter the physician presented to me states that on the advice of an “orthopaedic medical consultant”, the claim was denied. Having some understanding of how the world really works, I am left to wonder if this is really true. Did a medical consultant actually review and deny the claim? I suspect that this never occurred and if it did, was merely rubberstamped by a physician in the employ of the insurance company, i.e. a one-way verdict.

Furthermore, it has become increasingly clear that insurance companies are practicing medicine or at least its employees are – no doubt at the directive of senior managers. This is a wonderful game. They collect the premiums, play with the proceeds and issue a letter of denial to the insured, based on whatever evidence the company wishes to cite; moreover, they may or may not have reviewed the issues. Suffice it to say that they refuse to pay the bills for which they are inherently responsible.

It should be noted that in this instance, the patient-physician had consulted many other specialists over the years for her medical problem and had been subjected to a variety of treatments which were universally ineffective. These were of the “approved” variety. Indeed, she had been unable to be functional from a physical perspective and frequently could not attend to her practice. Following ten laser therapy treatments, she was relatively asymptomatic, able to travel abroad, ski and essentially, resume a normal lifestyle.

This issue focuses on our major concern: when were insurance companies licensed to practice medicine and overrule the medical decisions of the competent, licensed physician? What gives them the right to decide what types of treatment are approved, effective or appropriate and how do they obtain that right? The answer – this status appears to be silently conferred by political regulatory bodies influenced by the campaign contributions channeled to their subsidiaries. In essence, it is self-licensing by the insurance companies and until this practice ceases – meaning never, under current standards, it will continue unabated. Solution – collaboration by the public sector and the medical profession to recognize and understand the problem and initiate war on these nefarious practices in a unified manner. As each day passes, more and more patients – particularly now when many individuals have lost their jobs, have run out of savings and lost their investments, directly or indirectly as the result of criminal activities of the financial sector – really require insurance coverage. Collective efforts must be initiated to force insurance companies to cover the medical expenses for which they have contracted and deny their right to make arbitrary decisions, particularly those contrary to the opinions of independent medical professionals.

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