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Their incentive to deny benefits

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Posted: Tuesday, April 7, 2009 11:00 pm | Updated: 1:29 pm, Mon Apr 18, 2011.

When you have health and disability insurance coverage, you hope you'll never have to use it. But when you need the coverage, you have every reason to expect the insurance company to pay up.

Too often, though, that's not the case. Denial of coverage has reached epidemic proportions in this country. It's one of many serious problems we face with our for-profit health insurance system.

Here's a telling local example I learned about recently.

In 2004, Alan Wright was a senior security specialist with top-secret clearance at Raytheon, where he had worked for 20 years. His job involved protecting classified documents. When the World Trade Center was attacked on September 11, he was part of the security team tasked with protecting the Raytheon employees and buildings in Tucson.

Earlier, in 1996 and again in 2002, Wright had open-heart surgery. His medical expenses were fully covered by MetLife, the company that handles Raytheon's health plan. But by 2004, Wright's health had deteriorated to the point that his doctor said continuing to work would "significantly impair his long term health." The doctor declared Wright 100 percent disabled.

MetLife didn't agree. The company denied Wright’s request for disability pay and said he was able to continue working. Wright took his case to court. In 2008, a judge agreed with Wright and ordered that he receive benefits.

How did MetLife come to the conclusion Wright was healthy enough to work? They relied on the opinions of doctors who had never examined the patient.

These doctors weren’t disinterested parties, not by a long shot. One of them worked for Network Medical Review, a company that makes about $2 million a year deciding whether MetLife claims should be paid. The other wrote more than 400 medical reviews a year for MetLife.

You don't get steady work reviewing cases for an insurance company by being impartial. You’re expected to deny coverage whenever you can.

As I read the judge's decision in Wright vs. Raytheon, I was struck with the blatant bias of the doctors hired by MetLife. One insisted Wright's problem was mainly due to stress, even though Wright's doctor described serious cardiac disease. Though Wright had lung-related problems that made his breathing extremely labored, the other doctor repeatedly refused to consider the pulmonary problems in his review.

But the most amazing moment was when one of the doctors wouldn't accept the conclusion that Wright had a restriction of blood supply to his heart. The reason? Wright had to take a stress test, and he could only continue exercising for three minutes, which wasn't long enough to get an accurate measure.

Barry Kirschner, Wright's lawyer, doesn't blame Raytheon, which is known for offering its employees excellent health coverage, for MetLife’s decision. He sees it as a larger problem with the way our for-profit health benefit systems work. According to Kirschner, the system encourages arbitrary denial of coverage as well as delay. The longer a company draws out these cases, the more likely the covered individual will be forced to accept lesser benefits. “People who are disabled need relief immediately," Kirschner said. "Delay results in further harm."

And there's another problem, Kirschner continued. "There’s insufficient sanction to deter abusive behavior." Because of the law governing this type of case, Wright couldn’t ask the court for damages due to the hardships he incurred while waiting to receive his benefits. At most, insurance companies have to pay the benefits they denied if the ruling goes against them. It's as if a judge told a convicted bank robber, "Just give back the money you stole, and we'll forget the whole thing."

The quality of someone’s life shouldn't hang on a company's bottom line. When there’s a financial incentive to deny coverage, the patient is the one who will suffer every time.

Dave Safier is a regular contributor to Blog for Arizona.

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