OPINION How many horror stories will it take before Congress decides to act on the most ignored problem in the present healthcare debate, denials for people with insurance?
In September, San Francisco's KPIX-TV reported the story of Rosalinda Miran-Ramirez of Daly City, who woke up one April morning with her left breast bleeding and her shirt soaked in blood.
She was rushed by her husband to the emergency room at nearby Seton Medical Center, where doctors found a tumor. Fortunately the biopsy was benign. Less benign was Miran-Ramirez' insurer, Blue Shield which initially approved her emergency room claim, then denied it, demanding she pay the full charges, $2,791 under the dubious assertion she "reasonably should have known that an emergency did not exist."
After reporter Anna Werner called Blue Shield, the company decided to pay. Big of them.
We've seen this act before. In 2007, Cigna denied a liver transplant, recommended by her medical team, to 17-year-old Nataline Sarkisyan of Northridge. After national protests organized by Nataline's family, community, and the California Nurses Association/National Nurses Organizing Committee, Cigna relented -- a week too late, and tragically Nataline died.
In a recent interview with New America Media, Cigna's then-communications director, Wendell Potter, now an insurance critic, noted that "this is not an isolated case. People need to realize that there is a corporate executive who often stands between a patient and his or her doctor. That's the reality."
Why? It pays. Insurance companies make money by selling policies they never intend to make payments on.
In August, researchers with the California Nurses Association and National Nurses Organizing Committee uncovered previously hidden data on the California Department of Managed Care Web site revealing that six of California's biggest insurers have denied on average nearly one-fourth of all claims every year since 2002. For the first six months of 2009, PacifiCare rejected 40 percent of claims, Cigna 33 percent.
Predictably, the insurers went ballistic, issuing a stream of denials about their denials. It's all paperwork, or merely battles with doctors and hospitals, they insisted. These denials don't mean people are being denied care.
But, they are, every day. The insurers claim the procedure is "investigational" or "experimental" or the policy did not cover that procedure, or the patient had neglected to disclose some prior health problem.
Even if many of the denials the insurers themselves reported to the state are just "paperwork," they are a reminder that 30 cents of every private insurance healthcare dollar is wasted, much of it on warehouses of bean counters looking for reasons to deny claims.
Fortunately, California Attorney General Jerry Brown is now investigating the denial scandal.
But Congress and the Obama administration remain appallingly silent. Too timid to propose the most comprehensive reform single payer that would actually lift the hands of the insurers off our necks. Too timid to crack down on insurance company price gouging or denials of care.
Deborah Burger, RN is co-president of the California Nurses Association/National Nurses Organizing Committee.