Lift­ing the veil on life-and­death claims de­ci­sions

Jamaica Gleaner - - BUSINESS - Cedric Stephens

DR AL­FRED Dawes is a med­i­cal doc­tor. More pre­cisely, he is a gen­eral la­paro­scopic and weight-loss sur­geon. Gram­marly, a dig­i­tal writ­ing as­sis­tant, has rated me as be­ing among the top 10 per cent of its sub­scribers who use unique words. Should I be flat­tered by be­ing listed among this elite group, or dis­miss that la­bel as a sub­tle sales pitch de­signed to get me to buy the ser­vice? Hap­pily, I have a free, al­l­know­ing source of in­for­ma­tion. It ex­plains what sur­geons like Dr Dawes do. La­paroscopy, by the way, is a type of surgery that uses smaller cuts, or in­ci­sions, than those that gen­eral sur­geons make.

Dr Dawes is also a con­trib­u­tor to this news­pa­per. His Oc­to­ber 24 ar­ti­cle ‘One man’s fight with his in­sur­ance com­pany to treat his deadly can­cer’ caught my at­ten­tion. I read it sev­eral times. The sub­ject was Kinte Men­dez. The ar­ti­cle de­scribed Mr Men­dez’s ex­pe­ri­ences af­ter he took out a crit­i­cal-ill­ness in­sur­ance pol­icy seven years ago. Crit­i­cal-ill­ness in­sur­ance pro­vides money when cer­tain kinds of fa­tal ill­nesses are di­ag­nosed.

In May of this year, the pol­i­cy­holder was di­ag­nosed with an ill­ness that is fa­tal. Ini­tially, the in­surer de­nied the claim. Pol­icy funds were ur­gently needed to pay for the next round of chemo­ther­apy to com­bat the “ag­gres­sive and deadly dis­ease” and to keep him alive.

“Time is run­ning out,” Dr Dawes wrote. Mr Men­dez “would have to take it (the claim) up with the com­pany’s le­gal de­part­ment, if he didn’t like it”, the ar­ti­cle read.

The rea­son for the in­surer’s re­fusal to pay the claim was that the in­surer’s med­i­cal direc­tor ad­vised its claims of­fi­cial that the pol­i­cy­holder’s ill­ness was caused by skin can­cer. Skin can­cer was not listed in the pol­icy as a crit­i­cal ill­ness.

COM­MON MISDIAGNOSIS

The cor­rect di­ag­no­sis for the ill­ness, which is “so com­mon in Ja­maica that we rou­tinely screen preg­nant women and do­nated blood for its pres­ence”, was adult T-cell lym­phoma/ leukaemia (ATLL), ac­cord­ing to Dr Dawes. It is caused by a virus, HTLV-1. Lo­cal and over­seas med­i­cal ex­perts agree that this form of can­cer “could show up first in the skin but spread through­out the body, ul­ti­mately caus­ing death. No­body has ever been cured of ATLL”.

Sev­eral things both­ered me about the way the claim was han­dled:

• The pol­i­cy­holder was en­gaged in a life-and-death strug­gle in which he was get­ting pro­gres­sively ill. At the same time, he had to be fight­ing his in­surer to get money to pay for ur­gently-needed chemo­ther­apy med­i­ca­tion.

• There was ap­par­ently no mech­a­nism in the in­surer’s claims process for it to get an ex­pert, quick and in­de­pen­dent re­view of a claim when a claim was mis­han­dled, although it was sell­ing pro­tec­tion against crit­i­cal ill­nesses. The com­pany acted as an ap­peal and supreme court.

• The claims of­fi­cial dis­played a lack of em­pa­thy to the pol­i­cy­holder.

• The claims process was opaque.

• The tech­ni­cal com­pe­tence and ex­pe­ri­ence of the claims of­fi­cial were un­cer­tain. Three days af­ter the ar­ti­cle was pub­lished, Mr Men­dez sent me copies of two let­ters via email. They were writ­ten by a haema­tol­o­gist/on­col­o­gist and a ra­di­a­tion on­col­o­gist. They con­firmed Dr Dawes’ opin­ion.

The US and Cana­dian board­cer­ti­fied ra­di­a­tion on­col­o­gist stated that “my clin­i­cal de­ter­mi­na­tion is that Mr Men­dez does not meet any ex­clu­sions based in the pol­icy and hence should be cov­ered in ac­cor­dance with his in­sur­ance plan”.

The Na­tional In­sti­tutes of Health/Na­tional Can­cer In­sti­tute web­site lists ATLL as an “ag­gres­sive non-Hodgkin lym­phoma” whose signs in­clude “bone and skin le­sions”. This was the source that he ref­er­enced.

I con­tacted the in­sur­ance com­pany head on Oc­to­ber 29. I en­quired about the rea­sons for the com­pany’s re­fusal to pay Mr Men­dez’s claim. I also asked to see a spec­i­men copy of the crit­i­cal-ill­ness con­tract and the opin­ion of its med­i­cal con­sul­tant. Pri­vately, I won­dered if the claim was be­ing man­aged in com­pli­ance with in­ter­na­tional stan­dards.

The in­surer’s fi­nan­cial state­ments are pre­pared in ac­cor­dance with In­ter­na­tional Fi­nan­cial Re­port­ing Stan­dards. I have con­sis­tently ar­gued for im­prove­ments in how claims are han­dled by in­sur­ers over the course of many years. Were there any good rea­sons why the stan­dards for the pro­vi­sion of in­sur­ance ser­vices should be lower than those for ac­count­ing trans­ac­tions?

The re­sponse of the se­nior as­sis­tant gen­eral man­ager was very dis­ap­point­ing. He ap­pears not to have grasped the size of the rep­u­ta­tional dam­age that the poor han­dling of Mr Men­dez’s case has done to his com­pany’s brand.

A sim­ple ad­mis­sion that “we screwed up” would have been a good place to be­gin. No ad­mis­sion of guilt was of­fered. His 601-word doc­u­ment and the spec­i­men pol­icy were just that: words. It was as if he had not read Dr Dawes’ ar­ti­cle or the com­pany had learned noth­ing from its in­ter­ac­tions with Mr Men­dez. It was cold and clin­i­cal.

In de­scrib­ing how claims de­ci­sions are made, he wrote: “This (claims) com­mit­tee in­cludes a chief med­i­cal doc­tor, a lawyer, the claims man­ager, and an un­der­writ­ing man­ager, who de­lib­er­ate and as­cer­tain whether the claim qual­i­fies for pay­ment in ac­cor­dance with the terms and con­di­tions of the in­sur­ance pol­icy.”

The com­pany’s se­nior of­fi­cial is ig­no­rant of the In­ter­na­tional As­so­ci­a­tion of In­sur­ance Su­per­vi­sors’ No­vem­ber 2017 403-page In­sur­ance Core Prin­ci­ples gen­er­ally, and specif­i­cally the fol­low­ing:

• “... a dis­pute may arise be­tween the claimant and the in­surer on the claims set­tle­ment amount

amount or cov­er­age. Staff han­dling claims dis­putes should be ex­pe­ri­enced in claims han­dling and be ap­pro­pri­ately qual­i­fied,” and • “dis­pute-res­o­lu­tion pro­ce­dures should fol­low a balanced and im­par­tial ap­proach, bear­ing in mind the le­git­i­mate in­ter­ests of all par­ties in­volved. Pro­ce­dures should avoid be­ing overly com­pli­cated ... de­ci­sions should in­clude rea­son­ing in clear lan­guage re­lat­ing closely to the spe­cific dis­putable is­sues.” The In­sur­ance As­so­ci­a­tion of Ja­maica sought in a state­ment dated No­vem­ber 4 to “clar­ify the in­sur­ance claims process”. It did not. Mr Men­dez was treated sim­ply as an­other statis­tic – not the “liv­ing, breath­ing hu­man be­ing” that Dr Dawes de­scribed.

Later the same week, the in­surer fi­nally saw the er­ror of its ways. It de­cided to pay the claim. Were it not for Mr Men­dez’s de­ter­mi­na­tion to fight for set­tle­ment in the spirit of Dr Dawes’ child­hood hero, Kunta Kinte, the out­come would have been dif­fer­ent.

Cedric E. Stephens pro­vides in­de­pen­dent in­for­ma­tion and ad­vice about the man­age­ment of risks and in­sur­ance. For free in­for­ma­tion or coun­sel, write to aegis@flowja.com

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