From: "Ellis \"Don\" Penny" <[log in to unmask]>
Subject: Health insurance paying for surg
> Lee Swan is curious about getting insurance to pay for
pallidotomy.
> Curt Fried, M.D., in a lecture on the fetal cell
transplant program at
>the University of Colorado, said that the threat of legal
action was the
>surest and quickest way to get the insuror's attention and
action.
> Individual mileage may vary.
Based on my knowledge of organizational behavior in
bureaucracies*, I agree with this. Bureaucrats and
administrators
don't want trouble. They often take the path of least
resistance.
In this case, they think they can save some money by refusing
to pay for a patient's medical treatment, by calling the
treatment "experimental." If the patient accepts this answer,
they've saved some money.
However, they don't want a lawsuit, which they may lose,
and the collateral damage that goes along with it even if they
"win." ("Collateral damage" is a military term that means
destroying things you don't want to destroy in the process
of fighting the enemy. However, it applies in medicine;
a surgical incision is unavoidable collateral damage. Here,
the collateral damage is the negative publicity for the
insurer. If I started a lawsuit against them, my personal
inclination would be to make it as public as possible.) From
the bureaucrat's viewpoint, exposing his or her employer
to this scenario is bad for career advancement (or even
job retention) prospects- so the bureaucrat may feel an
inclination to be flexible.
Similarly, going to the press, AARP (if the insurer
offers policies to retirees), and so on may be effective;
again, the insurance company doesn't want to be the
center of a public controversy.
In my personal experience, I found that threatening
to complain to the state insurance commission was
effective for getting action from a recalcitrant auto
insurance company. The state insurance commission
regulates all insurance companies that do business in
the state.
-Bill Levinson
* I am not a lawyer, and none of this is legal advice.
I suggest consulting a lawyer before acting on these
suggestions.
