Printer Friendly Email a Friend PDF RSS Feed

Dynamic Chiropractic – March 27, 1995, Vol. 13, Issue 07

Why Do Insurance Companies Refuse to Pay Claims?

By Daniel Dahan, DC
Until about 22 years ago, it seemed that the idea of real discipline and punishment for the general insurance fraud against policyholders was a real joke. Interestingly enough in California the courts provided policyholders and those who represented them a very powerful legal weapon: the "bad faith" concept. From that point, many other states adopted some sort of bad faith law. As stated simply by William Shernoff, the crusading consumer rights lawyer who has halted big insurance companies for years and won, the law of bad faith states that if policyholders' claim have been unreasonably denied they can sue for more than the amount of their benefits. The insured can collect damages for mental suffering and all economic loss caused by the company's refusal to honor legitimate claims.

If it can be shown that the insurance company's conduct demonstrated a conscious disregard for the rights of a policyholder, then the policyholder can sue and recover for punitive damages. The purpose of punitive damages is to punish and make examples of companies that engage in outrageous behavior. Doctors, can you relate? How many insurance companies fall into this category? How many patients have been so unreasonably denied chiropractic coverage for their ailing backs, even thought the results of the treatments have been more than rewarding and so inexpensive compared to standard medical care? I have been practicing for over six years and I have seen in the last two years chiropractic coverage being either reduced, limited, or completely denied.

It would seem with the myriad of suits that are filed daily across the country that insurance companies would feel intimidated by the possible losses they could incur, not withstanding the embarrassment from the bad publicity. Yet insurance companies consider themselves notoriously aloof from these legal attacks and continue to enjoy an everlasting power. An insurance adjuster can decide at any time to investigate, evaluate, negotiate or terminate a claim, despite that many claims adjusters lack sufficient education, qualification, experience, and medical knowledge to make these decisions. Take this adjuster and give him a chiropractic patient's claim; now we're in real trouble. Although there is no question chiropractic has gained greater public recognition in the last few years, it has also certainly shown to have become more and more limited. The average chiropractic coverage seems to vary by 12-24 visits per year or between $500-1,500 per year. In today's economy and compared to medical reimbursement, these numbers are too often ridiculous. Any chiropractor would agree that for a reasonable treatment plan to be successful it deserves time and effort. And as it is a well established fact, the chiropractic doctor is, per all counts, the most qualified doctor to render spinal manipulation.

So if you have read this far, the same question remains unanswered. Why do insurance companies refuse to pay my claim? I believe I have the answer. Medical doctors have almost always enjoyed a very powerful tool: the MD degree. Marcus Welby, MD, has always been the triumphant savior and his kind, unadulterated compassion for his patients has given our generation a notion of not only expertise, but love and humanitarian pride that a doctor can have. I would be very curious to know what Marcus Welby, MD, was charging his patients for the care he rendered along with his hospital. Did you ever wonder what the reimbursements were? Did you ever wonder why these details were never discussed on the show? The answer is simple. The image of the MD was loving, not arrogant; caring, not selfish; compassionate, not greedy. Now I ask, is there any way I can practice with those same genuine principles and also get my claims paid? Indeed I can, I do, and so can you.

For years now I have had MDs who work in my clinics and I've enjoyed all the benefits the medical offices enjoy, yet still have practiced chiropractic as an art, a science, and a philosophy. I have been teaching this concept around the country with many doctors finally understanding that there is no reason to compete for patients with the MDs. To the contrary, with the proper set up, the MD can work for you and with you, send you his patients, while you benefit from the scope of his expertise, public recognition, almost unlimited insurance coverage and community endorsement. The question is, how can one do all this legally and ethically yet make it economically rewarding? There's one way: the multidisciplinary clinic. Although this is a very complicated subject to discuss in a few lines, suffice it to state that the system has worked for many doctors around the country and continues to grow successfully and aggressively.

Experience and time have taught me that a good set of contracts can save one from a long, difficult and very expensive journey through legal routes that seem to have endless ramifications and bottomless wells that require a constant flow of funds. The next step is to understand the medical protocol. MDs have a clear and very specific understanding of their role and limit their own expertise without hardly ever trying to overstep these boundaries. As an illustration, our orthopedic surgeon would not set a fractured femur and also prescribe an antibiotic for an upper respiratory infection, even though his license entitles him that right. He would refer the patients to a lung specialist or to a general practitioner for proper care. There are obviously some complications which need to be well taught and understood regarding the coding and billing of all services rendered in multidisciplinary clinics. Without going into great detail about the advantages of working with MDs in my office, the benefits (professional, medical, financial) are very rewarding.

There is a definite way today to practice chiropractic with love, compassion, respect and recognition, and get will paid for all your services. I love my job. I love my patients. And I am well paid for it. Can you think of a more perfect practice?

Daniel Dahan, DC
Seal Beach, California

To report inappropriate ads, click here.