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1 in 5 medical claims in California are routinely denied by health insurance companies

09/23/2009
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A report from California recently set forth that 1 in every 5, a whopping 20%, of all medical claims in California are routinely denied by health insurance companies. This is the case even when the patient’s physician has recommended the requested care.

A collaboration between the California Nurses Association and the National Nurses Organizing Committee studied the performance of health insurers in California between 2002 and June of 2009. Their findings are shocking and the examples of denied care are frightening:

  • Bob Scott of Sacramento needed radiation and chemotherapy for a brain tumor in 2005. Kaiser denied the treatment, saying the 57-year-old was too old. He died six months later.
  • Nick Colombo, a 17-year-old from Placentia, needed a special procedure for bone cancer. PacifiCare denied the treatment. After numerous protests, the insurer reversed the decision. But it was too late and Colombo died.
  • Kim Kutcher of Dana Point was scheduled to have back surgery when California Blues denied authorization six days before the planned operation. She ended up having to pay $60,000 out of pocket and is still fighting to get reimbursed.

I had been in the insurance industry for several decades before joining my current employer “in the light” and the insurance industry never ceases to amaze me.

I am one of those people horribly addicted to smoking and I am desperate to quit this dangerous habit. My physician recommended I start taking one of the drugs shown successful for aiding in kicking the habit. So, I went to purchase this smoking cessation aid only to be shocked to find out that my health insurance plan, which covers all prescription drugs, will not cover the $130 initial one month supply of this drug. I can afford it, but many people cannot.

It amazes me; the Carrier will pay $ 250,000 to remove my lung, provide radiation and chemo, in the event I develop lung cancer from smoking, but they will not help me avoid the agony and the significant exposure to them by covering this piddling sum to possibly prevent the catastrophic event.

It has been proven, scientifically, that acupuncture will relieve pain; yet unless acupuncture is performed by a medical doctor for surgical anesthetic purposes, the Carrier will not pay. Inexplicably, they will pay for a variety of Orthopedic, Neurologic, or Anesthetic provided procedures without question, but Certified trained Acupuncturists, not MD’s or DO’s do not qualify. Pay the Chiropractor, that’s OK.

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