>
> "Olin"
comcast.net> wrote in message
> news:p5-dnYARibWcQ6HanZ2dnUVZ_u-unZ2d@comcast.com...>>
>> "InfoSuperHwyRoadKill"
hellsgate.com> wrote in
>> message news:a1__i.7454$A71.1409@bignews9.bellsouth.net...>>>
>>> "Olin"
comcast.net> wrote in message
>>> news:T-ednX3w74hTPKbanZ2dnUVZ_hOdnZ2d@comcast.com...>>>>
>>>> "InfoSuperHwyRoadKill"
hellsgate.com> wrote in
>>>> message news:DRL_i.7064$A71.3595@bignews9.bellsouth.net...>>>>>
>>>>> "jakdedert"
bellsouth.net> wrote in message
>>>>> news:BOE_i.5010$2I3.4101@bignews2.bellsouth.net...>>>>>
>>>>> Well, since you haven't been back yet, I take it you were really
>>>>> interested in this;
>>>>>
>>>>> "If you have insurance outside a group policy, and you make use of the
>>>>> benefits, that is often justification for the insurance company
>>>>> dropping
>>>>> the client." - Joseph Crowe
>>>>>
>>>>> "California state law prohibits insurance companies from canceling
>>>>> coverage after a claim has been filed, unless the individual health
>>>>> plan
>>>>> member made a material misrepresentation on the medical history
>>>>> application."
>>>>>
>>>> Do you have any idea how easy it is to get around that?
>>>
>>> It does not really matter. The *law* is what it is. See above.
>>>
>>
>> Actually, it does matter. The courts are filled with such cases, and the
>> carriers lose about as many as they win.
>>
>> The law, whatever it says, is only as good as the enforcement, and a
>> policy holder's knowledge of what can and can not be done when a possibly
>> wrongful cancellation takes place.
>>
>>> "If you have insurance outside a group policy, and you make use of the
>>> benefits, that is often justification for the insurance company dropping
>>> the client." - Joseph Crowe"
>>>
>>> That was the assertion. Making use of the benefits *is not* the
>>> justification for the insurance company dropping the client.
>>>
>>
>> Well, I do know this much. There's fraud detection software available and
>> being sold to all manner of insurance carriers, and the first red flag is
>> filing a claim.
>
> I'll bet the first thing the software does is check to see if it is
> finished -- damn lazy software, would that not be the logical time to see
> if a claim is legit?
>
> As an old programmer, (as in it has been a long time since -- '87 to be
> exact) my question is what else should it be? The first sign of fraud
> would be that you applied in the first place, the 2nd would be making a
> claim, which could narrow down the potential area of fraud. The third
> would be that you've moved to Nigeria and Dr Muboto is treating you.
>
I'm guessing that's what the programmers thought as well. Sort of speaks
quite eloquently as to the real purpose of the biz.. to get your premium
dollars and keep them.
>
>>
>>>>
>>>> Practically anything can be, and often is, construed as a "material
>>>> misrepresentation" of medical history.
>>>
>>> Actually we don't know the pertinent, but if I recall, the questions
>>> regarding past health are fairly clear, as in Do you now have or have
>>> you
>>> ever had or been treated for Cancer? YES or NO.
>>>
>>
>> Granted, but I've seen cases where the answer was truly no, but when
>> cancer developed, it was claimed by a carrier that is has to have been
>> pre-existing because that type doesn't show up overnight.
>>
>> The devil's usually in the details.
>>
>>>>
>>>> Not health related,
>>>
>>> No it is not. The rest is not Joseph hearsay, but another experience
>>> with different rules entirely.
>>
>> Actually, they're not all that different. Nor is the business model used
>> by the carriers.
>>
>
> The business models may not differ, what they guarantee are very
> different. That is why I stayed on Joseph's statement. Once you have
> health insurance in place and settled, it can't be cancelled by the
> insurance company unless they cancel everyone and pull out.
>
You'd be surprised what can be done to a claim that's already settled.
Basically, you're right, but that will never stop the carrier from trying to
reneg on something with a battery of new tests and different doctors down
the road.
> I have stated that is why I hate to change health insurance companies and
> have only done so a few times. I am getting to the age that I doubt I
> ever change again. The current system sucks. It is adversarial. I think
> everyone would be better off if they could make life decisions without
> having to consider their ability to receive adequate
> health care, so it is perceived that I am taking a stand here that I am
> not. I just don't have trouble with the ins and outs that everyone else
> here have.
>
I don't either, once the issue has been shown to be valid. At that point,
the checkbook should come out and the benefits spelled out in the policy be
upheld. Time was, that was the case. Those days are long gone. Now, the
majority of carriers will play the game that says their clients don't know
what they're doing and if you act tough enough, they'll fold and we're out
less money. Sure, they lose big occasionally, but they win small enough
times to far outweigh what they have to pay out on the few squawkers they
lose to.
>> And really, it was never about the insurance for
>>> me. It was the great debater's assertion that using the benefit was
>>> justification for dropping the client. That is not and never is the
>>> justification because it is against the law.
>>
>> Of course it is against the law, but it is used, and the reason is
>> simple.
>> Ten policy holders file a claim. The first rule is to deny. It's not
>> unreasonable to expect a good number of them to just walk away from the
>> claim and go another route. For the ones who squawk loud enough, the
>> claim's eventually paid, assuming it's valid. The result is clear... the
>> carrier saves a ton of money, even though it pays out possibly more than
>> it would have otherwise on a single claim or two.
>
> I both read the book and saw that movie, but I have never (should never
> say never) had the problems you describe but I have never bought from the
> debit man either. Do they even still have them?
>
Sad to say, but today it's not merely the low rent carriers who pull those
stunts. Nearly all do that we work with, and we work with about thirty of
them, including the single largest workers' comp and disability carrier in
the country. That one's already been fined in several states for denying
valid claims on several occasions.
>>
>> It is very clear what the
>>> justifications actually are, and if I am not mistaken with health
>>> insurance, must be discovered and made in the first year or two. After
>>> that, I think even the liars are home free.
>>>
>>
>> Which is why most claims are treated as having been filed by liars. At
>> our
>> little place of business, the hurt workers who get their benefits are,
>> almost without fail, seen as people who know how to "game the system,"
>> and
>> the effort is almost always to look for some way to deny the claim
>> outright.
>>
> Are you talking work comp? If so, as an employer who has experienced both
> trouble FINDING work comp outside the state pool for some business and
> bullshit work comp claims from employees, who can blame the employer or
> the insurance company?
>
Anybody. Trust me, there was a time when workers' comp was gamed and gamed
soundly. That's not the case any more. It's virtually impossible to game it,
though some surely try.
If you get an employee who's filing a bogus claim, prosecute 'em and throw
'em in jail. Not all that difficult. But, that does not include denying
valid claims, and that sort of thing goes on far more often than you might
imagine. Nor does it entail a Human Resources Department making the decision
on how long it takes to recover, as there's one huge employer here whose
corporate policy basically cuts in half every recovery estimate on any
injury you care to name. At that point, you no longer have a job. And, you
no longer have any right to select your own doctor. 'Bout the only thing you
can do, when the boss decides physical therapy is appropriate treatment for
a blown out knee, torn ligaments or even traumatic brain injuries, is opt
out of workers' comp altogether and file under private health insurance if
you have it. And, there's another major employer here that has threatened an
employee that they'll go to his private insurance and get his coverage
denied.
That employer is trying their best to argue him out of federal court as we
speak.
In that segment of insurance, hardly anybody has clean hands, but the bottom
line is the law now allows hurt workers to essentially be treated as liars
from day one to settlement.
And yes, my company deals with workers' comp. But, they also deal with case
management on disability claims, short and long-term, as well as
catastrophic health and injury claims.
>>> but sure insurance related, I've got some personal
>>>> experience on just how far a carrier will go to avoid writing any kind
>>>> of
>>>> check.
>>>>
>>>> Nationwide told us they were rescinding our policy after a fire. Their
>>>> stated reason was that we had not told them about a bankruptcy in Texas
>>>> some years earlier. Trouble with that claim was twofold... their agents
>>>> were STILL telling potential customers a bankruptcy was no problem at
>>>> all... and as it turned out we had iron-clad proof that not only had we
>>>> told them about it... they had the self-same proof in their files all
>>>> along.
>>>>
>>>> Soon as their rainmaker found out that little bit of information, he
>>>> advised changing their tune toote suite.
>>>>
>>>> Do not even try to intimate that insurance carriers won't bend the law
>>>> to
>>>> the breaking point, and sometimes beyond, to avoid payment. They do it
>>>> because, by and large, their customer base knows diddly squat and they
>>>> have the same view of your premium dollars as does an armed robber.
>>>> I.E.,
>>>> it's their money that you're just holding onto for a while.
>>>>
>>>> Granted, that's casualty versus health, but I know way too many health
>>>> insurance adjusters who've told me the principle goals are precisely
>>>> the
>>>> same... to keep the money, and I've watched clear evidence of outright
>>>> fraud by companies and carriers cross my desk many times over the past
>>>> several years.
>>>>
>>>
>>> Well, from *if the shoe was on the other foot* department and as a
>>> capitalist, if *I* owned the insurance company, and somebody pulled a
>>> Moe
>>> and had no insurance for years, found out they had Cancer, called me and
>>> lied to me to get me to pay their bills, I wouldn't pay them either. Is
>>> that unreasonable?
>>>
>>
>> No, that's not at all unreasonable, and I'm quite sure that happens far
>> more often than it ever should. Folks committing fraud against an
>> insurance company should be prosecuted, and when they're found out they
>> usually are.
>>
>> When it's shown that fraud is not part of the deal, that's when the check
>> book should come out, and more often than not, that's not what happens at
>> all.
>>
>>>> Insurance is known as a racket for a reason.
>>>
>>> You don't have to have it. Just ask Moe. You don't even have to have
>>> car insurance in Tennessee, contrary to popular belief.
>>>
>>
>> If you have a mortgage on your home, you do, and if you don't, they'll
>> provide it for you; no choice at all. If you have an average job, you'd
>> be
>> unwise to not have health insurance.
>
> Actually, again, you don't. The bank will place insurance on the home and
> charge you for it, but you don't have to have it. If the home burns and
> its the banks insurance, it ain't your problem.
>
But that's the point. If you don't have it, they provide it and charge you
for it. At that point, if you don't want it, your options are sell the house
and move into a rental or pay off the mortgage. Of course, you can also show
them proof of self-insurance capability, but if you have that kind of money
lying around, you might as well pay off the house.
> And for the average job/unwise not to have health, I can't give it to you
> both ways. It can't be a racket if you think it wise to own it -- that
> there just don't make sense.
>
Makes perfect sense if a catastrophic illness or injury strikes. Better to
have something you're gonna have to fight tooth and nail to maybe help some
than to have nothing at all but your own bank account.
>
>>> I don't know this lady's circumstances. As the system is now, if she
>>> deserves to have her bills paid, then I hope she gets them paid.
>>>
>>
>> So do I, and I full well realize my own view of insurance is rather
>> jaundiced from personal experience, as well as conversations with folks
>> in
>> the industry who've confirmed some of the worst horror stories you've
>> ever
>> heard about the industry.
>>
>>> The real problem is that this lady probably couldn't afford health
>>> insurance.
>>>
>>> She tried a desperate measure because she can't afford chemo even more.
>>>
>>> But the Moe's of the world think because she can't pay for it, she don't
>>> deserve it because she chose having a car, a phone, and a TV with cable
>>> instead of health insurance.
>>>
>>
>> A tv with cable is a drop in the bucket, compared to the cost of
>> insurance
>> these days... especially if you can't get into a group policy situation.
>> And, TENN Care went belly up because of it's own abject incompetence, not
>> actual Tennessee clients overusing the system.
>>
>
> My cable TV comment was a paraphrase out of Moe's mouth. Jak eloquently
> kicked his ass for his asinine statements regarding the health
> insurance/personal possession bullshit.
>
Recall that. Personal possessions are irrelevant when it comes to health
issues and insurance coverage... unless some moron is using settlement money
to buy tvs, cars and such.
In that case, the dude has no one to blame but him or herself if and when
the carrier finds a way to pull the plug on those benefits..
