The Reality of U.S. Health Insurance Companies and Denial of Claims

Many individuals in the United States experience frustration and disbelief when their health insurance companies deny their claims. While some might consider these denials as exaggerated, the reality is far from ideal. This article aims to shed light on the common practices of U.S. health insurance companies and the impact they have on patients' healthcare experiences.

Profit Over Patients

Health insurance in the USA operates on a for-profit basis. Every dollar spent on claims is a dollar not made in profit. For instance, when a patient like myself undergoes a yearly physical, any additional tests or treatments can be seen as an unnecessary expense, reducing the profit margin of the insurance company. Here’s a personal experience that illustrates this:

Personal Experience

I visited my personal care physician (PCP) for my regular yearly physical. During this visit, my PCP, who might be referred to as a GP in the EU, noticed my PSA levels were higher than average for my age. Since my family has a history of prostate cancer, further testing was necessary. The insurance, however, initially approved the biopsy.

After the biopsy results came back clear, showing no cancer, I received a letter from the insurance company stating they were declining payment. Their justification was that the biopsy was "unnecessary as I am healthy and biopsy at my age is not necessary".

Denial of Claims for Arbitrary Reasons

U.S. medical insurance companies view the need to pay out on claims as an “undesirable consequence” of being in the business of providing insurance. They prioritize their revenues over patient care. Insurance companies could care less about the quality of medical care, as long as they can justify paying less. Here are some disturbing examples from my personal experience:

Example 1: Mood Stabilizer Prescription Denial

When prescribed a mood stabilizer due to adverse reactions to other medications, the insurance company denied coverage, opting instead for medications on the market that I had previously found unsuitable. Despite my efforts to fight the decision, the denial persisted until the situation stabilized on its own.

Example 2: Ambulance and Hospital Stay

In another instance, a broken patella required an ambulance, a five-day stay in the hospital, major surgery, and seven months of physical therapy. Two months after the accident, I received a bill for the ambulance ride, as the insurance refused to cover it. The insurance company eventually paid after negotiations, but the experience was distressing, given the critical nature of the situation.

Arbitrary Practices

Further, companies engage in discretion that is far from transparent. For instance, my mother, who managed a couple of medical offices, faced the issue of claims being consistently ignored. She sent duplicate claims to insurers several days apart, hoping to catch their attention. Some insurance companies simply ignored the first claim, hoping that the issue would be overlooked.

The Impact on Patients

The denial of claims and the arbitrary practices of U.S. health insurance companies significantly impact patient care. These practices can delay necessary treatments, subject patients to financial stress, and at times, even place their health at risk. As a result, I am seriously considering leaving the USA for healthcare reasons.

It is imperative for patients and policymakers to address these issues, advocating for more transparent and ethical practices in the healthcare insurance industry. The well-being of patients should always be the top priority.