Friday, December 21, 2007

This is a Toughie

[Welcome Industry Radar readers!]

Perhaps you've heard this:
As the parent of both a 20 year old and a 16 year old, my heart goes out to these parents. Having known others who've lost a child, there are no adequate words of consolation.
But their insurance company didn't kill her.
The harsh reality is that the insurer can only promise to pay for (part of) a procedure. Whether or not a given procedure is actually performed is up to the patient (or, in this case, the parents of the patient) and the health care providers. The insurer has no say in whether or not a transplant (for example) takes place.
Yes, this is hard.
And yes, there will be those who fault "the system:" the health care providers who want to be paid for their efforts (and to cover their malpractice premiums), the "heartless" insurance company that had misgivings about paying for the procedure.
But the actual choice belonged solely to the parents and the provider.
Nataline (the 17 year old at the heart of this tragedy) apparently received a bone marrow transplant from her brother. Did Cigna (the insurer) pay for this? Was it considered experimental? We just don't know.
And we don't know the particulars of the liver transplant issue, either. Many policies now limit such procedures to specific "centers of excellence," for example. Was this the case here? Again, we just don't know.
At the last minute, Cigna rethought their decision and made an exception for Nataline. And once again, we don't know why (although we can guess). Insurers make these decisions every day. It's called risk assessment and management, and it goes to the heart of the matter. Absent real data to support a procedure's efficacy, the carrier is bound - by contract - to deny payment. Yes, this is difficult, and yes, it is painful, but it is, in the end, reality.
As the company pointed out, there was little to suggest that the procedure would have helped in any case; we'll obviously never know. What we do know is that, despite the rhetoric and the pain, the insurance company didn't kill Nataline. The folks who refused to treat her or to have her treated, regardless of payment, did.
ADDENDUM: In rereading this story, I realized that I had missed some key points. None of them change my conclusion, but they do perhaps explain a little more why Cigna may have balked at paying for the additional procedure (liver transplant).
For starters, Nataline suffered from leukemia, a type of blood cancer. In an attempt to treat it, she received a bone marrow transplant from her brother. Unfortunately, she subsequently developed complications from this procedure, resulting in liver failure. Things went downhill from there; in fact, she was in a "vegetative state" since shortly after Thanksgiving. After researching this for quite a while, I couldn't find anything that indicated one way or the other whether folks in this condition are considered good risks for such a procedure.
Bob pointed out to me that, if she had had the transplant, the doctors involved admitted that "patients in similar situations who undergo transplants have a six-month survival rate of about 65 percent." That's not particularly good odds; we also don't know whether or not she was physically "up" for such a procedure. Perhaps that information will come to light.
Finally, lest those who would argue that the insurer's greed contributed (or caused) Nataline's death, and that a government-run system would have saved her life, I refer you here.
MORE: Attorney (and CPCU) Brad Ford has some interesting insights into this tragic situation. Money quote: "I don't believe it was unreasonable to have a 2nd opinion before spending an enormous amount of money on a treatment that may not work."
UPDATE: We've received some additional information from Cigna.
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