AlphaandOmega

A man's doctor orders him to have a procedure done. If he doesn't do it then the mans condition would get much worst. The man ignores the doctor and doesn't have the procedure done. Months later a small problem thus becomes a MAJOR problem. Now here is my question.

Lets say if the man had it done when the doctor told him then it would have only cost his insurance company around $5000. Since he didn't do what his doctor told him and the problem got worst it will now cost his insurance company $500,000. Should the insruance company still pay the 500,000 even though it is the man fault that it got worst by refusing early medical treatment.

reprise

My, you love the medico-legal ethics questions.

We'd need more information about the man's original condition and the general outcomes and prognoses of the various treament options including doing nothing.

I have actually been through a situation not dissimilar to the one you postulate (although medical insurance wasn't an issue, but outcomes were) in respect of cervical cancer, so I'll be interested to hear the different viewpoints on this. (FWIW, I took time to research my options, went for the least invasive option, and almost 20 years later haven't even had so much as an abnormal Pap smear since - the argument could be made that I "saved the government money by not opting for a more invasive and expensive treatment option).

Viti

I don't know if there is a "should" in there. Insurance companies can and do deny all kinds of claims for all kinds of reasons. You agree to their policies when you sign the contract and pay the premiums.

AlphaandOmega

I dont know. How about lets say the man was diagnosed with cancer. When the cancer was discovered it had just apeared and so if the man had the simple procedure to remove it then he would have been fine. Here the cancer has just started, but for some reason the man refused treatment the cancer spreaded. Now the insruance company has to pay for very costly medical treatment. When doctors are confident if the man had done something in the begining all would have been fine.

Lady I am talking about in your opinion morally should they have to pay.

Halsted

[Rant] Insurance companies do it all the time. They have crunched the numbers and have concluded that paying for expensive treatments and procedures for a FEW is far better for their bottom line than paying for much less expensive preventive medicine for EVERYONE. Believe me, the insurance companies don't care one iota about ethics or morality. They're in the business of making money, not keeping you well. [/Rant]

As to whether the insurance company should pay in the scenario you describe, I'm a bit biased when I say they should pay irregardless.

Tom Sawyer

Yes they should have to pay.

They have an agreement with the man that as long as he pays his monthly premiums, they will cover his medical bills. Yes in your example, it would be better if he had gone early and had the less expensive medical procedure, but in reprise's example it would have been more expensive.

The question is whether insurance companies should have the power to force people to have procedures that they do not want to have under the threat of denying coverage later. What if the $5000 procedure you mentioned had a 5% risk of death and the patient's condition had a 10% chance of not getting any worse? In that case, should they force him to either take those risks or not get any treatment later on?

What if the choice is not between $5000 and $500,000, but between a risky $5000 procedure and a not-so-risky $10,000 drug treatment? Would the patient's decision to opt for the more expensive option be a moral question in this case? What if the patient and the insurance company have different definitions of what's an acceptable risk?

The patient shouldn't have to base his decisions on what medical procedures to go through on what would be cheapest for the insurance company. He should base it on what he thinks would be the best course of treatment for himself, even if he is mistaken in those opinons. If he's wrong, he and everyone else will pay higher premiums as a result, but that's one of the costs of freedom. Personally, I think it's immoral to put monetary considerations into medical decisions, which is why I believe private health coverage to be evil and it's something the government should cover and spread the costs of the well-being of its citizens across society as a whole and not just have it go to those who can afford it.

Viti

As Tom Sawyer illustrated, there is really very few cases where the issue is so cut and dried. With cancer, there is no guarantee that any procedure will "cure" it, or any that are risk free.

I think we need a more realistic scenario to base opinions on. Let's say the patient is an alcoholic and is having liver problems. The doctor says if he stops drinking his liver will heal. The insurance company says it will pay for rehab and rapid detox. The man refuses treatment and continues drinking and his liver becomes kaput, should the insurance company pay for a liver transplant? Should he be put on the waiting list for a liver above people who don't drink?

Loren Pechtel

You're adding a lot of what-ifs to the problem that he didn't specify.

His original description is sparse but if there's nothing hidden in the details I would say the insurance company should be off the hook.

reprise

As I've said earlier, I've actually been through this one to some degree myself.

Almost 20 years ago I had a Pap smear which was abnormal - showing dysplasia. The cells which the Pap smear picked up were CIN II.

The options presented to me by my ob/gyn were :

1) Do nothing at this point but repeat the Pap smear in 3 months;

2) Perform a colposcopy to get a better idea of the extent and severity of the dysplasia;

3) Perform a cone biopsy.

I elected to have a repeat Pap smear done in three months. When the second Pap smear showed the same results as the first, I elected to have a colposcopy performed. The colposcopy showed extensive areas of dysplasia including significant areas of carcinoma in situ (CIN III). My ob/gyn was concerned that both the extensiveness and the depth of dyplasia might have meant that some dysplastic cells had been missed. At that point, a cone biopsy should have been a "no-brainer", yet my ob/gyn and I decided that I was at no immediate risk by taking a "wait and see" approach provided that I stuck to a strict follow-up schedule. There was no significant advantage to my having an immediate cone biopsy, and there were several potential disadvantages (my ob/gyn was aware that I wanted to have mroe children). Lest you think that my ob/gyn minimised the likelihood of the dysplasia spreading if some had been missed or returning if it had not, he didn't. I knew that the risk was substantial (I also knew that even with a cone biopsy, the risk was around the same or only slightly lessened).

Now you could argue that had the time come when I needed to have a hysterectomy due to invasive cancer, an insurance company had the "moral right" to refuse to pay for one because I didn't have a cone biopsy. Or you could argue that a "wait and see" approach was justified as there was no certainty that I would develop invasive cancer without a cone biopsy.

As I said, all of this happened almost 20 years ago and I haven't had an abnormal Pap smear since. I have had two mroe children born from uncomplicated pregnancies and if I developed invasive cancer tomorrow I would not regret the decision I made almost two decades ago. I would not be sitting around thinking "if only I'd had that cone biopsy then, maybe my life wouldn't be threatened now".

Wiploc

You could be asking whether the policy says they have to, in which case, the answer is that we don't know.

You could be asking whether the policy *ought* to say the company has to pay in that circumstance, in which case the insurance companies will be all for having to pay---and having to collect the higher premiums necesarry to support the higher payouts.

You could be asking whether the insurance companies ought to pay the money even if the policy says they have no obligation, in which case, as you can see, they have no obligation.

Or you could be trying some sort of analogy. You could, for instance, be hoping people will say the insurance company shouldn't pay in this circumstance, so that you can point out that, I don't know, that Bush warned Saddam about consequences so the US shouldn't have to spend money to rebuild Iraq. Or you could be hoping to catch the people who say the insurance company should pay by saying that they have effectively agreed that, I don't know, let's say that the insurance companies (or the government) should be able to require preventative surgeries, or should be able to forbid smoking and overeating and piercings and drinking below the age of 45.

crc