Doctor Versus Insurance Provider - Health Insurance Coverage Hazards

A Health Care Article Contributed by Ajishnu Sharma

Pitfalls of Health Insurance Coverage

There can be unusual circumstances when you feel your health insurance coverage has let you down. These issues may be not so unfamiliar when you take into account health insurance coverage as a whole. But on a personal level, such issues can seem very petty and disgusting to a patient. It has the potential to bring down the level of faith and confidence that a patient may have in his health insurance coverage as well as the insurance provider.

A very typical instance is when your physician (who might have been suggested by the insurance provider itself) and the insurance company disagree on certain specific treatment related issues, such as the price of a drug, or the need for a specific treatment procedure.

Issues in Health Insurance Coverage - When the Insurance Provider Can Say No

Many times a doctor may recommend special treatment which falls outside the aegis of the health insurance coverage. The insurance provider can choose to okay the release of money to cover such specialized treatment. On the other hand, the insurance company may choose not to cover such specialized treatment that falls outside the health insurance coverage.

This is an understandable stand; after all the insurance provider has, in the health insurance coverage package offered, agreed to consider the cost for only specific drugs and treatment. The insurance provider would be doing the patient a good turn if it agrees to cover any extra treatment outside what has already been agreed upon.

However, things can get petty when the insurance provider decides to put its foot down on covering certain medication prescribed by the physician. For example, the physician may have prescribed a certain medication that falls outside the range covered by a specific health insurance coverage plan. The physician may prescribe this medicine thinking it to be more effective in a particular scenario than other medication that is covered by the insurance plan.

The insurance company can refuse to cover this medication on the grounds of higher cost. From an emotional point of view, this may sound absurd, for what is cost, after all, when a life is concerned? But that is how it works at times. The insurance company may be willing to cover the particular medication prescribed, only after it has been proved that the medication covered by the health insurance coverage plan agreed upon is ineffective.

Legal Ramifications of Tricky Health Insurance Coverage Issues

This kind of a situation has legal ramifications as well. A patient may opt to sue the insurance provider for taking a stand like this. In fact, the Supreme Court has actually intervened in two cases where the patients have filed legal action against their insurance providers for malpractice, after the insurance provider refused to pay the cost for certain medication prescribed by the physician, quoting them to be more costly than the medication covered under the plan.

Whether the patient can win such a lawsuit is besides the point. The point is that when an insurance provider refuses to cover a medication or treatment procedure that has been prescribed by a qualified medical professional, a physician, a patient has every right to feel let down and seek legal redress.