Newspaper article THE JOURNAL RECORD

Commentary: Office Visit: Who Gets to Decide What Works?

Newspaper article THE JOURNAL RECORD

Commentary: Office Visit: Who Gets to Decide What Works?

Article excerpt

Much of television drama is fairly inane. Every now and then (probably without knowing it) television gives us a story line that is actually quite compelling. Recently I watched one of those lawyer shows - the type that portrays the principles defending the downtrodden against the vicissitudes of modern society and callous corporations. In this lawyer show the legal heroes were engaged in a lawsuit against a medical insurance company over their refusal to pay for an experimental procedure on a fetus in utero.

The insurance company's denial was based on a central issue. The procedure in question was clearly experimental and thus not covered by contract language. Naturally, the insurance company was portrayed as mean-spirited and corrupt. We all know it is easy to hate insurance companies - which is, of course, why the president changed his call from health care reform to health insurance reform. The whole point of the drama was to position the couple fighting for their rights, the brave surgeon willing to try this highly controversial procedure, and the crusading attorneys against this profiteering, uncaring, corporate monolith.

But despite our outrage, let's think this through. First, the relationship between the insurance company and its customers is contractual in nature. Party A pays Party B for insurance coverage under certain conditions. These conditions are generally clearly defined in the policy. Theoretically, by paying the premiums, Party A agrees to abide by and to be limited to those conditions. For the purposes of this drama, the policy stated that experimental procedures (which this clearly was) were noncovered services. So, by contract, the insurance company was within its rights to deny coverage.

Here is where it gets interesting. Insurance premiums are based largely on the losses the company incurs over time. So taking the emotion out of the equation, the case can be made that we actually want our insurance carrier to strictly follow policy language. …

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