Our Fraudulent Health Insurance System

Today I made progress on my research into our fraudulent health insurance system.

1. Aetna had refused to pay 50% of ordinary dental care that we had contracted. My provider was out-of-network so I did not expect full payment, but the brochure had a lovely big pie chart that said 50%. Instead, they paid about 20%.

The customer service representative told me to ignore the pretty pie chart showing "50%", and read the footnote in small type referring to an "allowance". They don't pay 50% of charges; they pay 50% of a secret allowance schedule.

The CSR objected to my use of the word "secret". They refused to publish allowance information or make it available to me in writing, but if I called in before treatment they would tell me over the phone what they would "allow" for that particular dentist and treatment.

This was not mentioned in the brochure. As the CSR stated, "All insurance companies work this way".

I have no reason to doubt that insurance companies may work this way, but it's not how most consumer transactions work. We expect to be told at the time of the contract what we're getting; otherwise there is no contract. To reserve the right to keep the benefit hidden unless you phone in at the time of the treatment - and not to let you know at the time of signing the contract that you have to do this - is tricky at best and within the ordinary meaning for fraud.

2. Aetna also refused to pay one claim at all. The CSR helpfully explained that the dentist's claim had not included the tooth number that the work was done on. The CSR helpfully said they would call and get the information, so perhaps something could be paid on this.

I didn't ask why that information was not requested before, or why they did not tell me they wanted more information. The answer is obvious: Insurance companies exist to make money. They make money by denying claims. They will deny your claim if they can. They have no motivation to ask for information that will result in paying a claim.

OTOH the dentist just wants to get paid. They have bills to pay too. All the time that goes into filling out forms to submit to insurance companies is waste. If they can submit a claim and then bill me when it is denied, fine; they get paid either way.

3. One may object to the term "fraud" since that word has a technical legal definition. However, it also has a common language definition: using trickery to profit in commerce.

Aetna and other insurers may be insulated from legal accusations of fraud by the clever language of their brochure, the general practice of the insurance industry, and the fact that they are fantastically wealthy organizations with no human sense of morality. But in the ordinary language of human beings: they are frauds. They use trickery to take your money.

4. What I have learned so far:
* It's not the CSR's fault. They're prisoners too. Blow off your steam before or after the call.
* Never to agree to an insured procedure without calling the insurance company first and getting a quote.
(If you're in an ER, good luck!)
* When your claim is denied, contact both the provider and the insurance company to see WTF. Maybe you can squeeze a little out of them.
* Think about whether some sort of reform would make sense. What if all the time wasted with billing codes and customer service calls were put to providing service?