Insurance has traditionally been a system of protection against loss in which a person agrees to pay a premium (amount of money) for a guarantee that he or she will be compensated, under certain conditions, if a specified loss occurs in the future. With regard to Medical Insurance the loss is meant to be the cost of health care necessary to treat an unforeseen illness or condition that the person develops.
Many people in the United States can not afford or choose not to purchase Medical Insurance. Others have insurance partially or completely paid for as part of their employment benefit package at their job. Still others choose to pay for insurance from their own funds, independently from their employer. Finally, although they may not have medical insurance, some people will pay for medical care as they need it, aka paying “out of pocket.”
The relationship between the Surgeon, the Insurance Company, the Patient’s Employer and the Patient can become very confusing. Many patients who have insurance through their work do not realize that their employer is self insured. That means the employer (often partly with the employee’s contribution) pays for each service for the employee. However, the process of paying is managed by an Insurance Company. Frequently, the patient thinks that the Insurance Company is responsible, and therefore will pay for any medical service that is necessary. In reality, the employer has usually placed preconditions on many types of service when the Insurance Company is contracted. In this way the employer can limit services to the employee, and the employee thinks that it is the Insurance Company whose rules and policies are obstructing care. The employer benefits by limiting services, and, therefore, reducing costs, while the Insurance Company is contracted to be “the bad guy,” and enforce these limitations. Both the employee and the physician are passive players outside this façade. All too often the patient and physician are the only parties present, or even reachable, when frustration sets in. Failure to provide complete health care despite providing “health insurance” is a carefully orchestrated game played by the employer and the Insurance Company.
Unfortunately, this is the most frequent reason that a person who has “health insurance” cannot get anti-obesity surgery when it is medically indicated. The employer has chosen to put an “exclusion” clause in the contract which states that anti-obesity surgery is not covered by the plan. Until a new plan is instituted the patient cannot have the surgery covered no matter how desperately he or she may need it. No amount of complaining to the insurance company is likely to change the situation. The best way that a patient can alter the system is to take the matter up with the HR department at their company. By letting the employer know that the employee expects complete coverage for life threatening medical problemsas part of their health care benefit, the employee is most likely to end the cycle of denial of this necessary care.
Patient’s faced with the possibility of having to pay for an expensive surgery by themselves, still have some options. There are a growing number of organizations that will now help finance the cost of an operation, so that the expense can be spread out over a long period of time. Most have a number of plans to fit the patient’s ability to pay. These tend to offer monthly payment plans that an average person can afford. When the patient considers the potential benefit of being able to have the surgery – specifically the possibility of adding years to his or her life – this option may often become the best choice. Anyone interested in learning more about these options should contact the office where we can help you find the information you need.