Health Insurance Denials and ‘Delay, Deny, Defend’ Practices Spotlighted in Wake of CEO’s Murder

(TJV) Navigating the complexities of health insurance claims has become a significant challenge for many consumers, even those who diligently pay high premiums. The increasing frequency of claim denials, often for services that patients believe are covered, has led to financial strain and delayed medical care.

Recent analyses reveal a troubling trend in the health insurance sector: a substantial rise in claim denials. A study by the Kaiser Family Foundation (KFF) found that in 2021, insurers operating through the Affordable Care Act (ACA) marketplace denied, on average, 17% of in-network claims. This statistic is particularly concerning given that these claims involved services provided by physicians and hospitals approved by the insurers themselves.

A 2023 survey by KFF revealed that nearly one-quarter (23%) of insured adults reported that their health insurance either did not cover a prescribed medication or imposed prohibitively high copayments, effectively rendering the medication inaccessible. This issue was more pronounced among individuals in fair or poor health, with over one-third (35%) experiencing such barriers.

The consequences of these denials are profound. Approximately 30% of adults taking prescription drugs have reported not adhering to their prescribed regimens due to cost concerns, leading to deteriorating health conditions and increased long-term healthcare expenses.

The denial rates among insurers vary significantly. Some insurers reported denial rates as low as 2%, while others had rates as high as 49%. This inconsistency highlights the unpredictable nature of claim approvals, leaving consumers uncertain about their coverage.

The financial architecture of many health insurance plans exacerbates these challenges. High-deductible health plans (HDHPs) require consumers to pay substantial out-of-pocket expenses before insurance coverage activates. For instance, in 2021, the average individual deductible for plans selected without ACA subsidies was $4,490.

Moreover, the prevalence of separate pharmacy deductibles means that consumers must meet a distinct deductible for prescription medications, further inflating out-of-pocket costs.

This financial burden is compounded by high copayments and coinsurance rates, which have nearly doubled over the past decade, intensifying the economic strain on patients.

The cumulative effect of these practices is devastating. Patients are often forced to choose between essential medications and other basic needs, leading to compromised health and financial ruin. The systemic barriers erected by insurance companies not only contravene the fundamental purpose of health insurance but also erode public trust in the healthcare system.

Pain News Network offers a case in point. Dean Peterson from Los Angeles experienced a sudden fainting episode due to an arrhythmia, with his heart rate soaring to 300 beats per minute. Despite obtaining preapproval from his insurer for a critical heart procedure, his claim was denied post-treatment. This unexpected denial left him in shock and facing significant financial burdens.

People Magazine reported that in Wisconsin, a woman named Ashley suffered a life-threatening miscarriage at 20 weeks. Her doctors determined that a surgical abortion was medically necessary to save her life. However, her insurance provider initially refused to cover the $1,700 procedure, citing a ban on abortion coverage. After enduring an eight-month appeals process, her claim was finally approved, but not without significant emotional distress.

These cases speak volumes about the often arbitrary nature of claim denials and the lengths to which patients must go to receive coverage for essential medical services.

Currently, the NYPD is conducting a manhunt for the murderer of United Healthcare CEO Brian Thompson.  As reported by NBC New York, the investigation has uncovered several enigmatic details that could provide insight into the suspect’s motives. Bullet casings recovered from the scene bore cryptic messages—“defend,” “deny,” and “depose.” A law enforcement official indicated that these phrases align with the title of a book on the health insurance industry that the suspect may have inquired about prior to the attack.

The Associated Press reported that the tactics employed by some insurers have been encapsulated in the very similiar  phrase “delay, deny, defend,” which criticizes strategies used to avoid paying claims. This approach involves delaying payments, denying valid claims, and vigorously defending these decisions, often leading to prolonged disputes and financial hardship for policyholders.

If the suspect in this case is apprehended and more detailed information becomes available, it could very well be that the shooter was a disgruntled customer of a health insurance company that adamantly refused to pay this claims. For now, this is mere speculation, however the words discovered on the gun casings are highly circumspect

Certain health insurance companies have faced significant criticism for their high rates of claim denials and controversial practices.

 An investigation by ProPublica revealed that Cigna used an automated system to reject claims without individual review, allowing medical directors to deny large batches of claims with minimal scrutiny. This practice led to numerous denials without proper consideration of the medical necessity of the services.

The New York Post recently reported that Anthem Blue Cross Blue Shield announced plans to impose limits on the covered duration of anesthesia during surgical procedures. This policy, affecting policyholders in New York, Connecticut, and Missouri, would deny claims if anesthesia time exceeded predetermined durations, potentially compromising patient care. The American Society of Anesthesiologists criticized this move, stating it prioritizes profit over patient safety.

Despite the prevalence of claim denials, a KFF study found that consumers appeal only 0.1% of denied claims under ACA plans. This low appeal rate may be attributed to a lack of awareness about the appeals process or the daunting nature of challenging large insurance companies.

The increasing incidence of health insurance claim denials poses significant challenges for consumers, leading to complete financial devastation and lack of medical care. While some insurers have been identified as frequent offenders, the issue spans the industry, necessitating greater transparency and accountability. Consumers are encouraged to be proactive in understanding their coverage, meticulously review denial letters, and pursue appeals when necessary to ensure they receive the medical care they are entitled to.