Cheating insurance companies deny patients proper care

By Aaron Gormley

We all know that there are many areas where health insurance is suffering in this country. One of the most frustrating examples of this is in the area of so-called experimental treatments. Insurers are routinely denying patients important healthcare because they have labeled certain treatments as investigational or experimental.

Another frustrating part of our struggling healthcare system is insurers who don’t cover preventative treatments that can actually prevent a more serious disease from forming. An example of this is that an overweight person who does not bring his or her weight down may develop diabetes.

TMJ Surgery

A good example of the ridiculous concept of experimental treatment is that of reconstructive surgery for TMJ. An alloplastic hemiarthroplasty of TMJ has been proven to be successful for fifty years. Insurance companies have labeled this surgery as experimental. To further confuse the issue, they will cover multiple autologous grafts that have a 69-90 percent failure rate.

Does this make even the slightest sense? Deny a patient surgery that is proven to work, but approve a surgery that is known to fail. It’s ludicrous. The health of Americans will never improve if insurance companies continually make these decisions.

Gastric bypass surgery

Gastric bypass surgery is a surgery reserved for those persons who are morbidly obese. They must be at least one hundred pounds overweight and tried other weight loss methods before being medically eligible for gastric bypass. However, just because a patient qualifies for the surgery does not mean the insurance company will cover it.

Although some insurance policies are beginning to cover this procedure, there are many that still won’t. Yet if these obese patients do not get help, they are at risk for diabetes, heart failure and other health problems. One study proved that very few states ensured coverage of obesity, even though it is seen as one of the most challenging health problems Americans face.

Not covering preventive care

Most people think of preventive care as a complete physical exam once a year, but it is much more than that. For instance, an overweight person can develop diabetes or sleep apnea if they do not get their weight under control. The insurance company will cover treatment for diabetes, but will not cover weight loss treatments that could prevent diabetes in the first place.

The same concept applies to conditions like sleep apnea. Sleep apnea can affect anyone, but overweight people are at a higher risk. If the insurance companies would step in and help overweight patients lose weight, they would not have to later cover conditions that were brought on by the obesity.

What the insurance companies say

Insurance companies try to insist that they will conduct reviews of new treatments to determine if they should be covered under their plan. Reading their handbook will lead a patient to believe that they are doing everything they can to research these treatments and eventually provide coverage. This is far from the truth, as this article shows.

If insurance companies will not cover a TMJ procedure that has been proven to work for fifty years, it is highly unlikely they will cover something that has been on the market for only five years.

The sad part is, while the insurance companies are dragging their feet about covering certain treatments, people continue to die. It’s a shame and the healthcare in this country will never be healthy until insurance companies are prevented from making these types of exclusions.

About the author: Aaron Gormley writes on all financial topics, from insurance scams to how to find CDs that yield high rates.

What an ex-gratia payment Is

Ex-gratia payments are made without legal acknowledgement of fault or liability. These types of payments are used in lieu of financial settlements that imply wrongdoing or contractual responsibility. The reasoning behind ex-gratia payments is by not admitting fault or wrongdoing, a defending litigant, accused or contractually obliged entity can avoid higher costs arising out of acknowledgement of responsibility, or fault.

In the insurance industry, ex-gratia payments may be assessed retroactively through legal process, or preemptively to bypass lawsuit, or additional financial obligations. If a company is not insured for particular liabilities, it may be to its advantage to issue ex-gratia payment in instance of undue hardship or circumstances beyond reasonable control of contractors. For example, irrespective of whether or not a business is insured for particular hardship of a contractor, according to Dr. Chundana Jayalath, a Chartered Quantity Surveryor, ex-gratia payments may be offered to contractors experiencing unforeseen adversity to avoid escalating costs.

In some circumstance ex-gratia payments may be simpler than others. For example, when elaborate insurance contract terms become involved, the possibility of misinterpretation of rights and responsibilities may arise. According to Robert M. Hall, a consulting lawyer and reinsurance expert, reinsurance companies may sometimes want to more closely examine their insurance settlements as ex-gratia payments may be unknowingly made under terms of contract.

The reason for Hall’s comments are due in part to renegotiation of insurance terms. In insurance, risk from insurance polices may be diversified by selling policies to reinsurers. Since an insurance settlement involves acknowledging contractual obligation to compensate the insured if the terms require such, a reinsurer is essentially agreeing to those responsibilities. However, in legal cases discussed by Hall, insurance terms that were re-negotiated did not warrant settlement making payment of such claims ex-gratia.

Sometimes, a court ruling may be required to determine if a payment is a settlement, an ex-gratia settlement or an ex-gratia payment. This is evident in the court cases discussed by Robert M. Hall. Moreover, Hall claims, a reinsurer, or company that obtains an insurance policy from an insurer looking to diversify its risk may not always be liable for insurance claims. Consequently, the inspection of legal contracts to avoid unintended ex-gratia payment may be justified in some instances.

In summary, ex-gratia payments constitute liability free compensation or imbursement for reasons of bypassing higher settlement expenses, legal costs or future liability for which non-ex gratia payment would create precedent or argument for. Employers or contractors may be able to avoid higher expenses by providing timely ex-gratia payment for reasons such as waiver of liability, undue hardship, or for contract mismanagement. The need for ex-gratia payment may be established internally within a corporation, or retro-actively as determined by a legal authority.