"Nameless, Faceless Medical Reviewers"

We have previously written about the serious problems which result when insurance companies hire doctors to perform “paper reviews” of insurance claims without ever meeting or examining the patient, and then use those paper reviews to justify termination of benefits. In an ERISA context, this is particularly difficult because claimants are denied in most cases the opportunity to confront those professional reviewers or to cross examine them to show they are financially biased or otherwise not competent to speak to the issues about which they have given an opinion. Even so, insurance companies in increasing numbers rely on these unnamed, unknown medical sources to justify termination of benefits. On December 14, 2014, 60 Minutes broadcast a piece which speaks in part directly to this issue and points out the fundamental unfairness, indeed the dangers which can result when insurance companies make claim determinations and deprive people of benefits to which they are entitled and which they desperately need.


Fairy Godmothers, Anyone?

If you are one of those who still believes the private health insurance industry is there to protect your interests you probably still believe in fairy godmothers, because you are really going to need a fairy godmother when you are sick or injured and the insurance company has to cough up cash.

For a thorough and detailed exposition on the motivations and tactics of disability income insurance carriers such as UnumProvident and Paul Revere, you should read the opinion of U.S. District Court Judge James C. Mahan in Merrick v. Paul Revere Life Insurance Company, et als, 594 F. Supp 2nd 1168 (D. Nerv. 2008).  It is a clear and convincing scorecard of the ways in which the insurance companies hit their policyholders, especially when they are down.

In the carefully worded, detailed opinion, by Judge Mahan, he finds that the reprehensible conduct of these insurance companies has garnered them “…hundreds of millions if not more…” in benefit dollars at the expense of physically, mentally, emotionally and economically vulnerable individuals (their policyholders).

The judge, after hearing all of the evidence presented by both sides, obviously concluded that the reprehensible conduct toward the clearly disabled plaintiff in the case was “…not the result of accident or inadvertence, but was part of a widespread corporate plan or scheme to augment profits through wrongful conduct targeted at disabled policyholders…”.

He went on to declare that the only conclusion he could draw after hearing all of the evidence and weighing the credibility of witnesses for both sides is that the defendants, Unum and Paul Revere, “…engaged in a widespread corporate plan, and conscious course of conduct firmly grounded in established company policy, to disregard the policyholder-plaintiff’s rights and the rights of tens of thousands, if not hundreds of thousands of other policyholders…”

The detailed and thoughtful decision by Judge Mahan puts the lie to opponents of health care reform. The system isn’t functioning for those most in need for it to function fairly, those whose health requires a claim to be made. When you are sick or injured, you are not at your fighting best – and that’s when the insurance sharks start their “delay and deny” act.

If our health system is ever to work properly, insurance companies will have to take seriously their obligations to policyholders and go beyond corporate profits only, “first, last and always”. Insurers will have to give fairness and “peace of mind” to policyholders who will then actually get what they paid for without the unconscionable “scorched earth” policy in regard to claims.

Only those who still believe in fairy godmothers can really believe that anything but government health reform is big enough to force such a change for the better.


Don't Be A White Bread Sandwich




Now that we are coming down the home stretch on the Congressional vote on health care reform, the hucksters are getting their baloney machines into high gear. Us guys who are just ordinary folks have to watch out to see that we don’t get slapped between two slices of white bread, doused in mustard and swallowed whole in the barrage of half truths and slanted statements by the people who don’t want change – our friends the health insurance industry. They just have it too good.

An article we posted just a few days ago (What You Can Do For Your Country) becomes more and more important as the battle heats up. Television and newspapers will be filled with pro and con position papers espousing the propaganda of whichever side is footing the bill. The best advertising and public relations minds are hired to press the public’s buttons so as to build support for their side.

We thought of a way to level the playing field in the struggle to come up with a fair law that would do the trick for most Americans:

Prior to Congress undertaking the job of writing a health bill, all of their governmental health coverage should have been canceled with a proviso that when they passed legislation, they would be covered by the new plan which they enact, and would have to pay health premiums for their respective policies out of their own pocket.

Only then, when they were in the same position as the rest of us, could they really act in the interest of all and come up with a fair program for the American people. But, it just ain’t gonna happen.

Many people seem to fall for the “Socialism” and “big government” labels fostered by the insurance company funded ads. But, what is Medicare, if not a “big government” run health care system? Yet, not one of those ads will say a negative word about Medicare because the American people have seen it in action and they know it works.

So, as we said a few days ago, first, it is vital to check who is behind any statement made by any individual or organization in this fight. A group may have a name that sounds strictly neutral – but are they? Know the real people and organizations behind the statement and you’ll be able to evaluate it properly.

Second, is to listen carefully to what is being said. If a statement says nothing more than “big government”, “Socialism” and “health czar”, it offers no help to you in evaluating the merits of the proposal. These are catch phrases which seemed to work before to defeat what the insurance companies don’t want and they are hoping it works again. Don’t allow it.

Evaluate arguments based on more than slogans because the health care issue is of vital importance to you and your fellow Americans. Health care costs are breaking the economy and threaten to become a full-blown economic disaster in just a few years if we don’t try to do something about it now. If each of us is not willing to consider sacrificing a little bit now, we could very well lose it all in the near future.

The false ogre of government-run health care is a false god. Look at Medicare, Armed Forces medical care and the Veterans Administration programs. They are clearly government-run and are operating just fine for many millions of Americans. Why can’t a government program fashioned on these examples operate just as well as an alternative to private insurance? Where is the proof that it wouldn’t?

With the vote in Congress on health care reform not due until some time in September, the health insurance companies have more than a full month to bombard Americans with propaganda that talks about everything but the real issues:

* Refusal to cover those with preexisting conditions
* Escalating health insurance premiums which fewer and fewer can afford
* 45 million Americans without any coverage at all
* A serious illness can bankrupt the average uninsured family

Any new law must deal with the real issues in the interest of all of us. Your input to your representatives in Congress will have a lot to do with the outcome. Don’t follow the insurance company party line – do what’s really good for you and the rest of us.





What You Can Do For Your Country

A recent article in The Washington Post reminded us of one of our pet peeves – people relying on studies or reports as incontrovertible fact without checking the background of the person or organization making the report.

The Post article pointed out that Representative Eric Cantor, House Republican whip, and Republican Senator Orrin Hatch both cited the Lewin Group as “nonpartisan” when speaking out against proposed Democratic health care change legislation.

The Lewin report predicted that 100 million people would go off the rolls of private, employer-sponsored health coverage if a version of a health bill was made into law. This was seized on immediately by opponents of new health care legislation and cited time and time again as an “independent” study. (The Congressional Budget Office came to an entirely different conclusion after a study. The CBO estimated that enrollment in a public plan would involve only 11 to 12 million people.

What was unsaid by Mr. Cantor and Mr. Hatch was that the Lewin Group is wholly owned by UnitedHealth Group, one of the nation’s largest health insurers. Further, Lewin is a part of Ingenix, a UnitedHealth subsidiary which was accused in New York for skewing doctors’ fee data to save health insurers millions in out-of-network insurance payments to policyholders. (Earlier this year, United Healthgroup agreed to a $50 million settlement with New York State on this issue).

This is a “nonpartisan” organization when it comes to health insurance issues? We think

With the health care battle entering its final stages, it becomes more and more important for people trying to untangle the complicated issues in health care coverage to take the statements of each side with several “grains of salt”. This is particularly true when either side makes a statement based on an “incontrovertible” source for its information. It is up to us the listeners to delve further into relationships and history to see if the claim of independence of judgment really holds up.

But, this holds true for more than just the present most important health care battle. Whenever a claim is made that raises any doubts, the listener should take it with a grain of salt. Who made the claim? Whom does the claim benefit? Who paid for the study upon which the claim is purportedly based? Are there relationships which might cast doubt on the veracity of the claim?


Prime examples are advertising endorsements. Without an affidavit as to how much the endorser received for providing the endorsement, who can believe in it? Yet, many people must or else the ad agencies wouldn’t spend so much time and money on them.

The upcoming health care decisions in Congress are vital to the future of America. Each person has a vital interest in the outcome. There will be many “nonpartisan” claims made by both sides. Get out your salt shaker and investigate them yourself.

The future of yourself, your family and your country truly depend on it.