Medical Insurance Treatment Myths and Realities

My share of my blog post on Movember got a really good reply with some well thought out points that I come across with clients every day. Some are well founded and understood, others things have changed as has the approach. I felt it was worth a blog post by itself.

Susan’s original post:

Good on you Jon-Paul, admirable cause, but it is my view that Health insurance company don't do Health prevention, you have to pay for this type of health service even if you have a mastectomy your health insurance won't pay for a re-build for want a better word, apparently its plastic surgery and its not covered to have you looking normal after going through harrowing surgery and treatment...

most areas of treatment or prevention in Men and Women through Insurance company are not covered, which is silly a colonoscopy can save the company thousands of dollars in later treatment and surgery...

but they won't cover it if its for prevention not because of cancer...... which is probably too late by then....WHY?

Thanks Susan, some very good points!

‘Health insurance company don't do Health prevention’

Yes this is correct, it’s expensive to do prevention, more expensive than fixing it when it’s really gone wrong. Medical insurance covers medically necessary treatment.

 ‘You have to pay for this type of health service’

Yes, which is why a regular visit and check up with your GP is the best way to minimise costs and ensure you catch things early.

 ‘Even if you have a mastectomy your health insurance won't pay for a re-build for want a better word’

Breast Reconstruction after a mastectomy can be a challenge with some providers, Sovereign in recent times got a pasting about their approach to the situation. I wrote a blog article about it, http://www.willowgroveinsurance.co.nz/.../breast-cancer... , at the time. Since then Sovereign have responded and changed their approach and the blog has been updated to reflect this too. Many insurers do handle this situation well, given it is a traumatic thing to have to go through

‘Apparently it's plastic surgery and it's not covered to have you looking normal after going through harrowing surgery and treatment...’

In normal circumstances this is how the medical and insurance people do look at it. In a reconstruction sense this is approached differently. The same can be said for going the other way too. Breast reduction often gets the cosmetic label. However if it is medically necessary, it can be tackled under your private medical insurance. The definition last time I worked through it was, Persistent back pain, Shoulder strap indentations, more than 250g per breast to be removed and cup size greater than a C. This may have changed slightly as a BMI measurement was talked about but I haven’t worked through a claim for this since then, but have had several paid for clients in the past.

 ‘Most areas of treatment or prevention in Men and Women through Insurance company are not covered’

I disagree, treatment is covered. It’s the preventative that isn’t so much, though some older plans do and some new plans will if you have every bell and whistle. An example of something that is borderline, is a Mirena, which is an IUD, usually used as a contraceptive. Where there is heavy period and conditions that cause persistent period problems, and intervention is required, the Mirena is the go to first tool for doctors, less invasive than a hysterectomy and less costly too. Insurance companies are paying for these to be used instead of the surgery where it’s medically necessary, even when they have exclusions for contraceptives. It is a case of having the right policy and right adviser to ensure things are taken care of in the right way.

‘which is silly a colonoscopy can save the company thousands of dollars in later treatment and surgery...’

Yes it can, however this is both an expensive and invasive test, doctors won’t request it unless it is necessary. Some may point at the insurance company but the insurance company works from the medical advice. If the Dr says it’s medically necessary, then the insurance company generally does pay for it. Also too most people don’t routinely do it just for the hell of it. However if there is a justified medical reason to be going looking, then these tests can and are covered. A strong family history of bowel cancer with family members of a particular age typically getting it, then a person of that family nearing that age could reasonably be justified as medically necessary for the testing. Assuming of course the family history has not created an exclusion. 

‘but they won't cover it if it's for prevention not because of cancer...... which is probably too late by then....WHY?'

This does become a bit philosophical. Reality is cost. The policyholder can only sustain a certain premium cost, to cover all the preventative treatment it comes at a cost, this cost is directly passed back to the policyholders. If you look at the balance sheets of most medical insurance providers they aren’t making huge profits, many are only breaking even as medical allows them to combine other benefits that they do make profits on. Southern Cross or largest provider is a not for profit, so profit taking is not part of the mix, but base premiums keep rising, because the treatment costs rise too.

It’s a difficult one as we have first world expectations on our health system with a budget far from the reality required. We already have medical insurance providers paying more than $2,000,000,000 per year in medical treatment claims on top of the health budget of $15bil, but there’s significantly more need that that. That $2bil is for the 25% of the population that have health insurance, the 75% that don’t have to deal with the public system with very little other support.

The people in our health system, the doctors and nurses, do the best job they can with the resources available. Reality is in a lot of cases the standard of care is better privately, because it's better funded. Often the people in private practice are the same people you see in the public system, because they work on both sides. Yes from time to time you will get exceptional care with the public system, but it can be a bit like playing roulette. Sometimes you miss out, the difference being your not playing with money, you're playing with your life.

If you want to have a frank chat about what can and cannot be covered give me a call. If we don’t know we will find out for you.