In Michael Moore’s new movie “Sicko” about the health care industry in the USA, much is made of the fact that Health Maintenance Organizations (HMOs) often deny coverage to patients because they failed to declare ‘previously existing conditions’ in their application. In the movie "The Rainmaker" a rookie lawyer defends a poor family against a decision by the insurer to deny their claim to benefits for treatment of their son who has leukemia. He wins the case, but the insurance company files for bankruptcy, so ends up paying nothing. "Never in Canada" you might say -- but, alas, such is not the case.
Although in Canada we have government funded health insurance, there are a growing number of services for which OHIP does not pay. For example, OHIP does not pay for all drugs, only for those generic drugs listed in the Ontario Drug Benefit listing. It does not pay for any ‘experimental’ alternative treatments such as acupuncture, or usually for any treatments given outside Canada. It does not pay for any vitamins or minerals that may be required for those on limited budgets, not having access to quality foods. Of course, it does not, nor has it ever paid for any long term disability (LTD) benefits necessitated by a chronic illness, such as cancer, heart disease, or rheumatoid arthritis. For LTD, Ontarians must rely on the woefully inadequate provincial disability insurance (ODSP), CPP, or private insurance. This is why some people pay premiums for extra insurance, often through their employers, provided by large multi-national insurance companies. When people buy this kind of insurance, they do so with the belief that that the ‘extra medical costs’ listed above will be covered, and that Long Term Disability payments will be granted for any chronic illness.
In 30 years of medical practice I have been less than enamored by the attitude of insurance companies to claimants for illness -- my patients. All too often patients have had to fight tooth and nail, often unsuccessfully, for any benefits. How can it be that people with chronic illness, who have paid hard-earned premiums for many years, are denied coverage for LTD, or for treatments that might help them get better? In "The Rainmaker" the prosecution shows that ‘all claims are automatically denied by the insurance company for a year’, hoping that the claimant will give up and go away. Now I wouldn’t want to suggest that companies in Canada would do that, but here is what can happen.
The patient goes to their family doctor and a chronic illness is diagnosed, for which there is no cure, and which prevents them from working in their chosen occupation. The family doctor refers them to a specialist who confirms the diagnosis. A claim is submitted, and on the basis of the written reports provided by the physicians it certainly ought to be paid. However, the ‘fun’ is only just beginning.
First of all there are the ‘bureaucratic’ delay tactics: this is where the company plays the ‘lost file’ game, or just simply takes a long time to pay the claim. If you haven’t kept photocopies of all your correspondence with the company -- watch out -- they may deny receiving the claim in the first place! Next, your file may be referred to the company ‘medical advisor’-- a physician. The physician has never seen you, and may make a decision based on the reports from the Family Physician, your Specialist, and, of course, their own biased opinion. If the letters from your family doctor or specialist are not strong enough or do not provide ‘hard evidence’, the claim may be denied. In “Sicko” medical doctors actually received bonuses if they denied a certain number of claims!
If not denied at this stage it may be recommended that you have an ‘Independent Medical Examination’ (IME), by physicians who are selected by the insurance company itself. Sound suspicious? Well, it is. Insurance companies appear to have a bevy of specialists, working for them of course, that will assess your condition in one brief session, and who usually tell the company you are fit to work, if not now, then in the future. Although you can refuse such an examination, you will probably be told that your benefits‘…will be discontinued or not allowed’. Somewhere in your contract, it will state that the company has a right to ask for an opinion from its own doctors.
By this time, you are probably frustrated enough with the whole game that it is making your chronic condition worse. You will feel angry and cheated, and justly so. Short of a long legal battle, there is not much you can do at this point. You have complied, you are following treatment, you are ill, maybe weak and tired, and a legal battle is the last thing you need. You may have already been spied on by private investigators and photographed by hidden cameras aimed at showing you lifting something, moving too much, or not taking your doctor’s advice. All of this is more ammunition for denial of your claim. Another nasty trick is to try to prove you are mentally unstable, or have a history of depression or anxiety. This somehow makes your physical illness less ‘real’, or more likely that you are ‘faking’ it.
Why do insurance companies do this? On the surface, there appears to be nothing illegal going on; they have the final word on any claim. But there is an underlying assumption that companies seem to operate under -- that patients would really prefer not to work, and are out to take advantage of the company. In other words in medical jargon they are ‘malingering’, out for a fast buck, so they can sit at home in front of the TV. The fact is that most of the time this is not the case -- for the most part people would prefer to work and lead productive lives. Or perhaps the bottom line is profit. There are many more claims these days for less definable illnesses such as Fibromyalgia, Chronic Fatigue Syndrome, and environmental sensitivities. People with these diagnoses are even less likely to receive deserved benefits, because there is often less ‘hard’ data to ‘prove’ they are ill. Companies are being deluged with these claims, and this is likely to increase as more psychological and environmental stresses take their toll on our lives. As these claims increase, companies ‘tighten their belt’ to offset them. However this is no excuse for the unconscionable, immoral and unethical behaviour that insurance companies pursue. What can you do if you are disabled? Each company has an insurance ‘ombudsman’ whom you can call or write, once a decision has been made in writing by the insurance company. If you get nowhere with the insurance company ombudsman, you can appeal to the Provincial Ombudsman who oversees the whole system. For further information on these avenues of appeal you can call or write for information on the ombudsman for your insurance company.