What You Need to Know About Health Insurance Part 5

Note: This is Part 5 of an 8 part series that is also being published in the Chester County Press.

“Your Doctor vs. Their Doctor”

In our last article we stressed the importance of recognizing the subtle difference between denying payment for insurance purposes and overruling your doctor for determining the healthcare you need. For, while this difference may seem subtle, it provides the healthcare insurance industry with its most powerful means of denying the care and coverage we expect from our so-called health insurance. Namely, the claim that their doctor can overrule our doctor for determining the healthcare we need.

As with any complex issue, we need to begin the discussion by separating the facts. First, your plan has carefully and deliberately given itself the absolute right to deny payment for essentially any reason it chooses. And, they do it through the contracts they require every in-network doctor, hospital and other healthcare provider to sign. Contracts we will discuss in a later article. But, rest assured, these contracts exist and they give your plan the right to deny payment completely independent of any doctor’s decision on the care you need. Consequently, the opinion of our plan’s doctor has nothing to do with the plan’s right to deny payment.  

So, why would your plan insist that their denial of coverage is based on their doctor’s disagreement with what your own doctor is prescribing? Because it causes you and me to fight the wrong war. In essence, it has us arguing our doctor’s opinion vs their doctor’s opinion where the merits of the dispute are lost in a fog of time and technical complexity, i.e., they win.   

Fortunately there is a better way to fight this form of denied coverage. It’s to immediately insist that the only doctor with any legal standing to determine the care we need is our doctor. The bottom line being that the opinion of our plan’s doctor is irrelevant. Case closed!

This approach puts us in the right fight. Yes, our plan still has a contractual right to deny payment. But, they have zero right to deny the healthcare we need. A fact our plan desperately wants to keep hidden, as well as one that forms the basis for the subtle difference referenced above. Because, tucked away in the same contracts that give our plan an absolute right to deny payment for insurance purposes, are equally strong provisions guaranteeing we get the very care our doctor is prescribing. The only question allowed by these contracts is whether the care is paid for by the plan or the in-network provider. But, that’s a subject for another article.

See Other Articles in the Series