When you make a health insurance claim, oftentimes your health insurance company will have a doctor employed by the company review the claim to see if it should be paid. The problem I have seen in a number of cases is the doctors reviewing policyholders’ claims are horribly unqualified to make fair decisions on those claims. For instance, if you make a health insurance claim for payment of medical treatment involving your heart, you would expect a cardiologist to make medical decisions for the health insurance company about your claim. A claim involving your heart, in other words, should be reviewed by a heart doctor. Would it seem fair to you if you submitted a claim involving treatment for your heart and it was reviewed by a general practitioner? Or if you made a health insurance claim involving brain cancer and it was reviewed by a pediatrician?
Nobody would think this is fair. Ever. However, incredibly, this is exactly what goes on all day every day in the health insurance industry. Health insurance companies put in place claim processing systems involving claim reviews by completely unqualified doctors. To compound the problem with this practice is that it is not disclosed to the policyholder. Instead, the policyholder is almost always sent a generic denial letter from the insurance company that doesn’t tell the policyholder the name of the doctor or the doctor’s specialty/qualifications. Why would the insurance company not want its policyholders to know whose opinions it is relying on to deny claims?