A while back, when the age range for a person to become a senior citizen was fixed at above 60 years, I posted an article here that explained why that change in the government policy was welcome. However, I also posted an opinion that that change made the taxpayer’s liability for paying the medical bills of people over 65 years old a lot larger. Also, many readers pointed out that they thought it wrong that a person who had paid for the medical care of her spouse a few years ago would have to pay more for medical care for a spouse or parent in the same category, even though the time period when the insurance would take effect had ended.

I thought I would add a few comments to that post. I should stress that, in my view, he makes some important points, but this is not an exhaustive list of all the issues.

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Avoid Health Insurance Mistakes

One of the common misconceptions that Ajay says that he would like to see clarified in this context is the use of the term ‘separate medical claim’. It is commonly thought that this term means that an individual must file a separate claim for a treatment they receive from a physician who was employed by a different entity, even if the same company was treating that person for an unrelated condition. That assumption is wrong. It is the same as saying that people have to be the claimants for a claim for damage to their vehicle even though they were the driver. The automobile insurer will cover the vehicle and will not cover the driver’s injury, no matter how serious. So, the benefit an individual receives must be fully spelled out in the benefit policy to ensure that the coverage is not under threat.

Another common misconception, which is related to the first, is the so-called ban on ‘frequent claims’. In any given year, a company has no control over whether an employee will have any medical claims at all. If an employee has a traumatic injury, or even a life-threatening medical condition, the company has no control over whether the employee will be able to manage the condition. If the Insurance Company finds that the employee is receiving more than expected in an effort to manage the condition, they will reduce their premium. However, once that period expires, they are responsible for the entire cost of the treatment.

Also, I do not know of any insurance company that can simply say, ‘We will pay no more than $25,000 for any individual claim’. That seems like a lot of money, but not really. Suppose the individual has paid $10,000 in premiums, or $15,000, or $20,000, so far. Say that they apply for coverage and get a $15,000 claim, which they have $5,000 to pay. What will the premium be? Would it go up? Would it not? Would it not pay part of the claim? Would they take the full $15,000, since the case was resolved after that time? They will pay what the insurance company says, even though they have not given them the choice.

Last but not least, the requirement to have a waiting period before the first claim can be made is a curious one, because it should be obvious that people have enough need for medical care that they can’t wait until a condition is ‘cured’. In most cases, the condition is chronic and will recur. So, the insurance company should not be penalized for providing care on a continuing basis. In other words, for example, the insurance company should be able to take the money that they would have paid for a claim during that waiting period and use it for other claims.

So, my questions are these:

Why should I have to pay more because I work for the same company that is providing the insurance?

Why should the individual who is seriously ill have to wait a few days or weeks before filing a claim?

Why should an employee who needs outpatient treatment be required to pay a deductible before the insurance company will pay for it?

Why should we all be expected to pay more, on the average, every year, so that companies can provide more benefits for those who work for them?

Needless to say, the entire system, which permits these benefit changes and the payment of more money to a small group of employees while raising premiums on all employees, is badly flawed. The system, in its current form, lacks fairness and transparency. The entire way that Americans view and relate to the insurance industry needs to be completely re-examined. We all deserve better, and the system of insurance companies creating policies and rules to provide benefits to those who are insured is not a viable way to provide health insurance for most Americans.

As an American, I would like to continue to have the privilege of paying a tiny percentage of my income to provide Health Insurance to My Family, and to not be penalized financially when my child gets a potentially life-threatening medical condition.

PS – What do you think? Is there a reasonable system to provide universal health coverage? or do you believe the American system of employer-provided health insurance should be continued for now, with an option to allow individuals to opt out and pay their own way?

If you haven’t already, please sign the change.org petition below, which is demanding that the government immediately implement a comprehensive Public Option for Health Insurance.

Yes, sign.

PPS – What is your position on the mandate?

o read more about the power of a public option for health insurance in this country, please consider reading my book, “Wealth Inequality and the Erosion of the American Dream“, or my recent speaking engagements on this topic, or hearing my presentation on this topic on the podcast Brave New Films.

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You’re Guide to Getting Health Insurance for you and your family if you are not yet on health insurance gets educated about the options. Use this guide to help you make an informed decision about getting health insurance for you and your family. A Guide to Getting Health Insurance for you.

Who Do You Think Will Be Voted off Healthcare.gov in 2014? This is a fascinating question, and, quite frankly, I don’t know.

Sen. Jack Reed (D-RI) has already introduced a bill that would require an actuarial study to determine which sections of the Affordable Care Act could be repealed or modified.

On the other hand, the Republicans have already begun talking about repealing the law in whole. Rep. Greg Walden (R-OR), a co-chair of the House Republican Steering Committee, said that the law, while greatly improving the healthcare situation in this country.

There will undoubtedly be many Americans who face the dreaded “donut hole” in their prescription drug coverage.

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