Health Insurance Exclusions and Refusal to Pay.

[DawnCt1]

In the Hartford Courant this morning; Sorry I don't have the article. A self employed man bought an insurance policy for himself and his family through an independent broker. At some point after that his 18 year old honor student, eagle scout son attends a party. Even though he has a designated driver, after consuming a significant amount of alcohol (1.6 ), he drives his pickup truck into a telephone pole. He recovers from his injuries at the cost of $247K. His health insurance looks at the bill, the cause of the accident and says; "We aren't paying". There is buried in the policy an exclusion that states that they will not pay for care for any injuries sustained while consuming alcohol or drugs not ordered by a physician. The father successfully sued the agent, although not enough to cover the hospital bill. Apparently there are only four states in the USA that permit this clause. How do you feel about it? My feeling is, if there is that clause, it is irregular enough that an acknowledgement that you are aware of the clause should at least have to be signed. That is the case with motorcycle insurance and the "underinsured driver clause". You have to sign that you have been made aware that the additional coverage is available to you and you chose to decline. If the carrier can save the buyer some money, than the buyer should be able to chose that option, but not without disclosure. A bill is being introduced into the Ct. State Legislature to eliminate that provision. How do you feel about it? Most insurance companies do not have that clause so I can understand why the father in this case wouldn't have considered the possibility.

 

[AllyandJack]

I don't know....if we required written disclosure for every exlusion, we'd all be signing a lot of papers! I guess it's similar to a life insurance policy....if you don't wear a seatbelt, if you commit suicide, etc., you don't get to collect.

My policy doesn't cover TMJ unless there is an injury to the jaw - not stress-related TMJ. But, I can look at my policy BEFORE going to the doctor to make this determination. When you're being rushed to the ER, you can't really flip through your contract to see if it's going to be covered.

I'd be in favor of having something like this requiring a writing....something to do with emergencies, but not something that you have time to make sure you're covered before seeking treatment.

It's confusing, but I guess that's my unofficial position on the matter.

 

[DawnCt1]

I don't know....if we required written disclosure for every exlusion, we'd all be signing a lot of papers! I guess it's similar to a life insurance policy....if you don't wear a seatbelt, if you commit suicide, etc., you don't get to collect.

:

For life insurance policies, it is pretty standard that one's beneficiaries do not collect in the event of suicide but MOST health insurance companies pay the hospital bill regardless of whose fault it is. And most states do not permit that type of exclusion. The insurance industry could take it all a step further and decide that they are not going to pay for smoking related illnesses; chronic bronchitis, COPD, emphysema and lung cancer, or they are not going to pay for weight related diseases such as heart disease, joint replacement surgery or diabetes. We have had a similar scenario with DSs oral reconstruction. Buried deep in our secondary dental policy that I cobra'd just for the occasion, it says that it will not replace teeth that didn't exist prior to the policy, teeth that are congenitally missing, etc. We are not asking them at this point to pay the lousy $722 for the missing teeth that they still owe us, but to pay for raising the surfaces of the abutting teeth. Our prosthedontist has now sent two appeals and we are waiting the results of the 2nd appeal before he appeals to the state in which the company does business. I did enjoy reading his request for the last appeal, "I would like someone to review the xrays, reports and all communications who has at least the same educational background and professional qualifications as myself". Anyway, back to the OP, with only four states allowing for this type of exclusion, I think that this particular insurance company is out of line. The father won his suit against the broker for failure to disclose that very important detail.

 

[dennis99ss]

I am shocked. I think someone has hijacked Dawn's login.

You sound like a liberal, trying to cheat those insurance co.'s out of their money



BTW, since this is a hijacked thread, I kinda agree with whoever is posting as Dawn. But, realistically, the ins. co. can do whatever they want. I do agree it should be prominent. It just helps the case for healthcare for everyone. Kind of like the more ins. co.'s do this, the more they shoot themselves in the foot since it simply causes people to want the gov't to become involved in the provision of health services.

 

[Teejay32]

I feel pretty conflicted about this. (since you asked ) I think private health care coverage has a conditional flavor to it anyway, only it normally deals with pre-existing conditions and bad habits. I don't like it. But I wonder if the time to address that passed already with the general acceptance of excluding or penalizing this or that part of the population that tends to be expensive. People who drive drunk are expensive too.

 

[DawnCt1]

I am shocked. I think someone has hijacked Dawn's login.

You sound like a liberal, trying to cheat those insurance co.'s out of their money



BTW, since this is a hijacked thread, I kinda agree with whoever is posting as Dawn. But, realistically, the ins. co. can do whatever they want. I do agree it should be prominent. It just helps the case for healthcare for everyone. Kind of like the more ins. co.'s do this, the more they shoot themselves in the foot since it simply causes people to want the gov't to become involved in the provision of health services.

No, You have got the wrong "take" on it. Letting the insurance company off the hook or at least not requiring that the insurance company provide "informed consent", makes it everyone elses problem. In all probability, that hospital bill won't get paid and then the rest of us, including all of the insurance companies are on the hook for it. It is not an arguement for socialized medicine. Good try though.

 

[dennis99ss]

I knew it was to good to be true. Thought you might have seen the light over the Holiday. I thought you were getting mad because the ins. co. snuck one by, and took the man's money. But, you were worried about the dr's not getting paid, and other ins. co's having to pay more in the future because the dr.'s would charge more to cover the write off. Amazing how two drastically opposing views come out of one simple fact scenario

Oh, at least we know it is Dawn, and not some imposter

 

[Mackey Mouse]

Wait a minute here!!!!!

I think that the insurance company should have some kind of warning on their policy about injuries as a result of alcohol consumption will not be covered....what if it was not a car and he fell down stairs and broke his neck but was drunk, would that not be covered and if so, who pays???? I do not really think that the hospital will eat the money so somehow it will fall back on the taxpayer or the next person who needs medical assistance will be paying more for his services..

If that is the case then people who have pancreatic cancer might not be covered for chemo and radiation or for surgery because they can link that cancer to alcohol...can they do that???

I also live in MA where I think the governor is trying to do something about the uninsured. And then I hear small business owners freaking out as they will have assume the costs of paying for these insurances...

 

[AllyandJack]

In MA business owners are bent out of shape because they'll have to pay $295. per employee per year for every employee that doesn't have health insurance. There is some arguing over circumstances under which one employee is covered under someone else's insurance. I'm on DH's plan....would my company have to pay? They shouldn't have to because they OFFER the insurance, but I don't need it. But, that's another topic for another time.

I think that anything that is excluded that will be done under emergency circumstances should be disclosed. When you don't have a chance to look at the policy to decide what's what, it should be clear that you understood.

What about the car insurance policy? They won't pay any of the expenses under the medical option?

 

[DawnCt1]

I knew it was to good to be true. Thought you might have seen the light over the Holiday. I thought you were getting mad because the ins. co. snuck one by, and took the man's money. But, you were worried about the dr's not getting paid, and other ins. co's having to pay more in the future because the dr.'s would charge more to cover the write off. Amazing how two drastically opposing views come out of one simple fact scenario

Oh, at least we know it is Dawn, and not some imposter

WRONG AGAIN...When the patient doesn't pay, then we all pay. The insurance companies increase premiums because hospital care goes up due to the number of people who don't pay. The physicians' bills would be negligible when compared to the hospital bill.

 

[DawnCt1]

In MA business owners are bent out of shape because they'll have to pay $295. per employee per year for every employee that doesn't have health insurance. There is some arguing over circumstances under which one employee is covered under someone else's insurance. I'm on DH's plan....would my company have to pay? They shouldn't have to because they OFFER the insurance, but I don't need it. But, that's another topic for another time.

I think that anything that is excluded that will be done under emergency circumstances should be disclosed. When you don't have a chance to look at the policy to decide what's what, it should be clear that you understood.

What about the car insurance policy? They won't pay any of the expenses under the medical option?

I thought Mitt vetoed that portion of it where the employer had to pay. Was there an override?

 

[AllyandJack]

I thought Mitt vetoed that portion of it where the employer had to pay. Was there an override?

Not yet. But, they apparently have enough votes to override, so I guess it's just a matter of time.

 

[DawnCt1]

Wait a minute here!!!!!

I think that the insurance company should have some kind of warning on their policy about injuries as a result of alcohol consumption will not be covered....what if it was not a car and he fell down stairs and broke his neck but was drunk, would that not be covered and if so, who pays???? I do not really think that the hospital will eat the money so somehow it will fall back on the taxpayer or the next person who needs medical assistance will be paying more for his services..

.

On a local morning show an "older" (all right, very old) gentleman called in and made a point that the 18 year old was drinking and should be responsible. I wanted to call in and say when the old geezer is sitting on his porch sipping his brew, and falls down a step or two, should Medicare not pay because he was drinking. The hospitals do end up eating it which is why many smaller community hospitals have had to close. The larger hospitals can stay afloat but do pass those costs onto the insured.

 

[Mackey Mouse]

Amen Dawn....

And I also heard the insurance thing might go through in MA. So sad for the small business owners who are already paying exhorbitant amounts of money for lights, heat, etc. etc.

 

[DawnCt1]

Another negative impact the exclusionary clause is having, is that physicians are not ordering drug and alcohol tests on trauma patients because there is a concern that the patients may get stuck with a bill that they can't begin to pay.
By not confronting the issue of drug and alcohol abuse, they are missing perhaps, an opportunity for appropriate counseling or treatment that would prevent a recurrance.

 

[Mackey Mouse]

What about treatment for cirrhosis of the liver? Will that not be covered now? I know it can be also caused by hepatitis....but it can also be caused by alcohol abuse.

 

[Teejay32]

WRONG AGAIN...When the patient doesn't pay, then we all pay. The insurance companies increase premiums because hospital care goes up due to the number of people who don't pay. The physicians' bills would be negligible when compared to the hospital bill.

People can't pay because hospital care is so expensive, and hospital care is so expensive because people can't pay....

 

[dennis99ss]

WRONG AGAIN...When the patient doesn't pay, then we all pay. The insurance companies increase premiums because hospital care goes up due to the number of people who don't pay. The physicians' bills would be negligible when compared to the hospital bill.

Sounds like an argument for national health care....

 

[mickeyboat]

I am the benefits administrator where I work, and have a copy of the insurance certificate which is sent to every employee when they enroll. The certificate is pretty clear regarding exclusions and limitations. Yes, exclusion for alcohol-related injuries is something a subscriber may not expect, but the exclusion was there at the inception of coverage. How much hand-holding do we need to do for people? Where do you draw the line?

Denae

 

[rayelias]

As far as I'm concerned (boy, am *I* gonna get flamed)...

How do I put this? Anyone who engages in risky, extraordinary, unneccesary activities that would put them in unusual, extraordinary danger, should personally assume the liability that they put themselves into. This would include drinking and driving (You wanna drink, don't drive. You wanna drink to excess... anything you do after you become so annhebriated that your judgement is compromised is your responsibility.)

I would also include activities such as skydiving for pleasure, snorkling in a river of Piranah, skateboarding without proper equipment (headgear, pads, etc), playing with firecrackers, and the like.

If you put yourself in a position that has a high likelyhood of serious injury to yourself or others and ignoring the proper precautions, you need to make a choice. Either don't do it, or assume the risk on your own.

I (and society) shouldn't have to bear the burden of someone's stupidity, laziness, ignorance, even if they did stay at a Holiday Inn last night.