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BarnacleBill's avatar

Should health insurance companies pay for the lastest technology or the most cost affordable treatment?

Asked by BarnacleBill (16065points) June 18th, 2011

A 34-year old woman lost her hands due to cancer. There have been developments in prosthetics, and there are now prosthetic hands available that have computerized chips inside them. The cost for these hands are $25,000 each, and therapy is needed to learn how to use them. Additionally, there are maintenance issues with them, and they will eventually need to be replaced. However, her health insurance coverage only covers standard, conventional prosthetics, such as hooks and pulleys, for hand amputees. When her doctor filed a claim for the computerized hands, her health insurance carried denied the claim, because there were other options available that were covered.

The state of Indiana Department of Insurance stepped in and said that the insurance company had to provide her with the computerized hands, which they did, rather than challenge it.

Was the insurance company exercising financial due diligence by rejecting the claim for the expensive computerized hands over the less expensive traditional hook and pulley prosthetic? Or should compassion overrule fiscal oversight? The money that pays claims comes from the premiums paid in by other group members, and not from insurance company profits.

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9 Answers

Cruiser's avatar

Obama Care would have shut down any chance for that lady to get those hands, force the other options upon her and prevented a lawsuit from forcing the issue as well. She is one lucky lady.

BarnacleBill's avatar

@Cruiser, but it has nothing to do with Obama Care. If you work at the same company as her, your insurance premiums will go up to offset the cost of those hands. If the plan is set up to pay $10,000 for posthetics, and the cost is $50,000, that money comes from the group. The computerized hands are an “elective” option.

WasCy's avatar

It’s an excellent question, and worthy of consideration. It’s especially worthy because of the wider implications of “all treatments” and “all cases”.

In any case, if the prosthetic hands are experimental or prototypical, then this is a moot question. Insurance doesn’t pay for “experimental” treatments, nor should it. Nor could we afford it if it did.

So I’d want to know more about the devices. How long have they been available and offered to the general public who needs them? How many other such hands have been made available to others? What is the cost history of the devices? Is there a middle ground between these cutting-edge devices and the bare-bones (no pun intended) “hooks and pulleys” devices?

gorillapaws's avatar

Heath insurance companies will gladly take as much money as possible from you, but should something happen and you actually need treatment, they’ll do everything they can to reject, delay, deny, etc. The problem is that you put the money upfront with the trust that they will do the right thing should you need it…

Another issue to mention is that insurance companies negotiate with the physicians, so even though it may cost $50k, they could only be paying like 5–10k. I don’t have any knowledge in this particular case, but I can assure you that doctors and hospitals aren’t getting paid nearly as much as it first appears.

augustlan's avatar

Isn’t there something like ‘best practices’ that determines which procedures/devices have the best cost to benefit ratio? Everyone should be able to get a reasonably functional and reasonably attractive replacement hand, but not necessarily the latest, greatest, best one available.

marinelife's avatar

I would think that the insurance company should reimburse up to the usual cost (of the hooks, etc.), and then any additional cost for electing the hands should be borne by her.

BarnacleBill's avatar

@marinelife, that is my thought, too. You have a specified benefit amount, up to $x. After that, you’re on your own.

It sometimes works that way with dental plans. My dental plan pays $2000 a year in benefits. With network discounts, that covers two cleanings, x-rays, and a few fillings. If I need a root canal or a crown, the unused benefit applies to part of that, but anything over and above I have to pay for myself. I end up having to wait to have dental work done until the next plan year starts. Most dental plans don’t cover implants, but will cover pulling your teeth and getting dentures. I am missing my front teeth, and the plan wanted to give me a partial plate. I opted to pay for two implants at the cost of $7000, and it’s like I never lost the teeth.

gorillapaws's avatar

@BarnacleBill what’s the point of insurance then if it’s not going to pay for necessary shit? That’s fine if you want to walk around without your front teeth, but I’d be pissed if I had to wait a year to get cancer removed because I’d used up my quota for the year. That’s not healthcare, that’s called “make the insurance companies rich at the expense of the health of the nation“care. We’d all be much better off pooling our money into a government plan, not having Execs siphoning out any of the cash for themselves and to run very expensive lobbying and PR campaigns from that pool and then paying for everything.

WasCy's avatar


Maybe part of the problem, then, is the way the insurance companies are regulated and what they are often required to pay for. What would your auto insurance cost, I wonder, if it were necessary to also cover routine maintenance, oil changes and car washes? When I buy auto insurance I can tailor it to the car: I get less (or none at all) comprehensive and collision insurance for the car as its value decreases. My health insurance will pay for pregnancy, though. Like that’s going to happen.

The point of insurance, after all, is not to make you completely whole again after a calamity befalls you. It’s to “defray” and “offset” the cost. If you want “gold standard” coverage, then you have to expect to pay for that, not pillory an insurance company for attempting to legitimately hold down its cost and live up to the letter of its policy coverage. (If they shirk a legitimate claim, then that’s another matter. I’m not here to defend cheats.)

Whether you like it or not (and I sense from your writings that you certainly won’t like it) the insurance company, the supermarket, the oil company, the cable company and every other company that you deal with each and only exist to make a profit. How they do it varies. How they provide the goods or services that lead to the revenue stream to make that profit also varies. The quality of the goods and services themselves varies. That’s why competition is a good thing, so that we can pick and choose the companies we wish to deal with.

My health insurance? I have zero choice. None at all, unless I want to (or am forced to) change employers. The health insurance company has my employer as a client, not me. That’s a problem. If we go to a not-for-profit and / or single-payer system, as many seem to believe will be “the solution to all of our problems” then our problems will be magnified to an extent you can’t even imagine yet.

But just wait. Maybe you’ll get to see it. Come back and give me the lurve then.

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