Insurance companies don’t make money by approving claims. The job of a case manager or insurance adjuster is literally to tell you that you aren’t covered, as much as possible, as often as possible.
To that extent, health insurance providers have their own doctors on staff, who will give evaluations that are favorable to the company. You agree to be evaluated by the doctor as part of your policy contract. This has been going on forever and that’s why insurance providers make money.
Similarly, insurance will cut off long term disability claims when there’s no end in sight because it’s cheaper for them to pay out a settlement than continue to pay LTD indefinitely.
Am a doctor and while I agree this is shady AF and should be further controlled, we do at least have some requirements. An insurance company has to use a licensed doctor, so their privately funded third party opinions don’t usually come from someone employed by them; just chosen by them. I’ve actually never had an outside opinion requested by insurance that overturned my initial diagnosis, and many times they actually help with new treatment suggestions.
What happens in my experience is that if they want to keep dragging it out, which they always do, insurance will just continue to try to claim that the original doctor and the outside party requested by insurance don’t really know anything and actually Karen the Case Manager at Manulife is the real expert. I’ve had that happen three times in the last two years. Frustrating though it was, the scathing letters I got to write to the company were sort of cathartic.
I think a very good start for all of this is that we should be generating the terms and paperwork at a provincial level and requiring all insurance companies use the same forms. You want a doctor to fill out your paperwork? Use the paperwork we’ve agreed on then. The first way they start miring people down is by sending out twenty page forms asking for every little detail of your medical history regardless of the claim, wasting huge public resources from doctors. From there it would be easier to standardize practice for insurance companies so that we have more ways of holding them accountable when they try to claim that the provided evidence is sufficient.
Edit to add: I don’t know if most people realize this but a lot of the time once the doc has given a diagnosis insurance isn’t actually trying to refute it. They’re trying to drag everything out until the patient is too exhausted or broke to fight anymore. It often works, they’re forced to go back to work because otherwise they’ll starve. Insurance doesn’t have to prove anything, just delay.
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Insurance companies don’t make money by approving claims. The job of a case manager or insurance adjuster is literally to tell you that you aren’t covered, as much as possible, as often as possible.
To that extent, health insurance providers have their own doctors on staff, who will give evaluations that are favorable to the company. You agree to be evaluated by the doctor as part of your policy contract. This has been going on forever and that’s why insurance providers make money.
Similarly, insurance will cut off long term disability claims when there’s no end in sight because it’s cheaper for them to pay out a settlement than continue to pay LTD indefinitely.
Am a doctor and while I agree this is shady AF and should be further controlled, we do at least have some requirements. An insurance company has to use a licensed doctor, so their privately funded third party opinions don’t usually come from someone employed by them; just chosen by them. I’ve actually never had an outside opinion requested by insurance that overturned my initial diagnosis, and many times they actually help with new treatment suggestions.
What happens in my experience is that if they want to keep dragging it out, which they always do, insurance will just continue to try to claim that the original doctor and the outside party requested by insurance don’t really know anything and actually Karen the Case Manager at Manulife is the real expert. I’ve had that happen three times in the last two years. Frustrating though it was, the scathing letters I got to write to the company were sort of cathartic.
I think a very good start for all of this is that we should be generating the terms and paperwork at a provincial level and requiring all insurance companies use the same forms. You want a doctor to fill out your paperwork? Use the paperwork we’ve agreed on then. The first way they start miring people down is by sending out twenty page forms asking for every little detail of your medical history regardless of the claim, wasting huge public resources from doctors. From there it would be easier to standardize practice for insurance companies so that we have more ways of holding them accountable when they try to claim that the provided evidence is sufficient.
Edit to add: I don’t know if most people realize this but a lot of the time once the doc has given a diagnosis insurance isn’t actually trying to refute it. They’re trying to drag everything out until the patient is too exhausted or broke to fight anymore. It often works, they’re forced to go back to work because otherwise they’ll starve. Insurance doesn’t have to prove anything, just delay.