This is pretty standard procedure in a lot of industries:
Health insurance will often initially deny coverage, either in the pre-approval or when you get the bill, but if you firmly follow up and hold their feet to the policy they will reverse that.
Even if you're uninsured, healthcare providers will usually settle medical debt for about 10c on the dollar if you threaten bankruptcy.
Home/auto insurance will often give you a black hole for claims; the adjuster won't get back to you for months at a time. But if you keep calling them enough to be annoying, they will usually eventually pay out.
Contractors will often fail to fix shoddy workmanship until you threaten to report them to the local licensing board.
Cops will often ticket you, but a surprising number of tickets get reversed if you contest them in court, oftentimes because the cop doesn't even show up. One of my friend's parents in high school vowed never to take a speeding ticket lying down; he was 5-0 on contesting them.
The IRS will come at you with the interpretation of tax laws that is most favorable to them given the data they don't have available, particularly if you are high-income. But if you actually know the laws and can show hard data (statements/receipts), you can usually get the bill they claim you owe reduced by 80%+ or even to $0.
Colleges will often increase their financial aid packages by thousands of dollars if you have a competing acceptance and are like "Well, I would love to attend your school, but financially it's hard for me to justify paying $X more than this other school I got into."
Companies will often increase their compensation offers significantly, sometimes by hundreds of thousands of dollars, if you turn down their offer.
It's all negotiation. They put forth an initial low-ball offer because most people accept it. If you make it clear that you are one of the folks who will make a stink about it, they'll often increase their offer significantly to get you to go away.
I think the law needs to change. Statutory damages for any initial refusal that is later overturned, whether by a court or by the company themselves. Treat it as breach of contract.
This is is to change the economics so that there is a cost to a business for automatically denying, just as there is a cost to the claimant when the business automatically denies.
> Home/auto insurance will often give you a black hole for claims; the adjuster won't get back to you for months at a time. But if you keep calling them enough to be annoying, they will usually eventually pay out.
Fortunately I live in a more reasonable country, where I don't have to keep chasing them; I can simply claim through the court system instead. I think the system works here - I haven't heard that to be a problem here.
I would agree with this solution, and also think that these other reforms to the legal system are necessary:
1.) The cost of the court system needs to go way down. It's not okay to have justice be a luxury good; every citizen needs to have a way of adjudicating and enforcing their rights.
2.) Laws need to be enforced uniformly. Right now the usual outcome for the squeaky wheel that files a lawsuit is that they get paid out in a decent settlement, the case is dropped, and the corporation goes right on screwing everybody else who doesn't bother to enforce their rights. Or it becomes a class-action lawsuit where the lawyers get $40M, the plaintiff gets $10M, and every other member of the class gets a check for $100. If a judgment for a class-action lawsuit is $10M, every member of the class should get $10M, not just the plaintiff. If this bankrupts the corporation, so be it: maybe their business practices were invalid to begin with.
3.) Relatedly, laws that are never enforced should fall off the books so we don't get this kind of "regulation by enforcement" that can be used to arbitrarily punish people, as well as wholesale shifts in the legal regime based on which party is in power.
4.) It should be easier to collect on judgments. It can take years for a judgment or settlement to clear your bank account in the U.S. Some people don't have years, particularly those with health conditions or living on the edge of poverty.
This is reality, but it is a bad reality. Nowadays it seems I find myself constantly having to "chase" things that I never had to in the past, just to get them resolved in a way that is not totally screwing me over. Every time some company fucks something up (always in their favor), it turns into a letter sitting on my desk that I have to call someone about, navigate through phone trees, submit this info, confirm that info, and remind over and over until it gets resolved. Particularly around any kind of insurance or any case where a company owes you money. Nobody pays unless you hound them relentlessly.
A consequence of this approach is that the insurance industry might as well not exist as far as I am concerned; they have poisoned their entire value proposition. I will not voluntarily do business with people who plan to screw me over.
A rule of thumb is that it's never worth taking out insurance on something that you can afford to replace in full yourself.
Note though that in many cases, insurance is mandated by law. In many states you have to have auto insurance. If you have a mortgage you usually have to have home insurance. The cost of medical treatment is such that a single accident can cost more than your lifetime earnings, essentially forcing an automatic bankruptcy. Indeed, the reason for the auto and home insurance mandates is often to pay for liability coverage in case you get sued for somebody else's medical treatment.
Given the dealings that I've had with the insurance industry, it seems that many companies realize that their function is just to tick the legal box. They have skeleton or nonexistent claims-handling departments that employees are frequently laid off from. The goal is to slow-walk any claims past the statute of limitations, so that nobody gets paid out anyway, but they can continue to collect the premiums because the government requires that everyone have insurance. (But then another phenomena is that people are increasingly ignoring the government too, such that they now offer "uninsured motorist coverage" to make up for cases where you're hit and hurt by someone who illegally doesn't have insurance.)
You're forgetting that all of this has an opportunity cost that most people simply do not have the ability to meet. Spending dozens or even hundreds of hours following up with companies that have a lot more capital, manpower and incentive to screw you over is not something the average person is either willing or able to do.
Yes. In California 75% or more of the roadside billboards and bus ads are for lawyers. Typically injury lawyers. They have their own slogans and jingles.
In the Bay Area they tend to be for AI companies, though I'm pretty sure I've seen at least one for an AI lawyer. (Meaning a general-practice lawyer that is actually a datacenter, not a human lawyer who practices AI law.)
It's actually kinda fun to look at the public transportation ads and see what they say about each major metro area. In the Bay Area most are for enterprise software vendors. In Boston most were employment ads with some obscure scientific or mathematical puzzle where if you solved it, it redirected to a biotech or software company's jobs page. In Baltimore, it was mostly for bail bonds.
The difference here is that oftentimes your situation can markedly deteriorate, sometimes irreversibly, as a result of that denial. And the "make a stink" can come at a time you're least equipped to deal with it.
> It's all negotiation. They put forth an initial low-ball offer because most people accept it.
And that's the problem. People having to make a stink because insurers are doing things that are in contradiction to the policy they wrote, if not the law, because private enterprise wants more money.
Private enterprise that has simultaneously almost singlehandedly caused the skyrocketing of medical costs, because the only way to make more money when your profits are regulated is to increase costs, and nobody except the consumer/patient is incentivized to do anything about it, quite the opposite - they're entirely happy to go along with it. And then insurers will stand up in Court and say "Oh, we're not denying care to our customer, we're just saying we won't pay for it. They're free to pay for it out of pocket." My old boss would have received a $1.8M bill for his daughter's care, born at 33 weeks. A coworker of mine had to raise a substantial portion of an expected $1.25M bill for a lung transplant for her son. My kidney stone would have cost $70,000 to have not been resolved (they went in, found infection, retreated and gave me IV antibiotics instead, and revisited the issue two weeks later, which had its own separate bill). My ENT had to put me on two expensive and useless nasal sprays for months so that when he recommended deviated septum surgery for an effectively blocked nostril (90%+ deviation) that insurance wouldn't deny it because (gasp, shock, horror) nasal sprays don't realign or open up cartilage.
Exactly. You shouldn't have to lift a finger to negotiate with a company where there is a written agreement that they owe you money or that you are entitled to a claim or similar.
This whole "you have to haggle for everything" culture we're putting together stinks.
An individual who makes a false insurance claim is committing a felony, but a manager who knowingly denies thousands of valid claims is rewarded with bonuses and promotions.
CEOs who who structures the company to denies as many valid claims as possible are handsomely rewarded by Wall Street for increasing margins.
Things really need to change at a core level in America.
>Few patients appeal when insurers decline to pay for their care. Many don’t even know they can. But new data show that when they do, they frequently win — in some plans, nine out of 10 times.
If 90% of denials that are challenged end up being reversed, and the delay in delivering the care that the insurer contractually agreed to deliver is deleterious to the patient's overall health and leads to prolonged suffering, why is this not a cause of action? Until there is some sort of downside introduced, the "deny til they die" health insurance model is going to continue to thrive at the expense of people not getting the care they paid for and are entitled to.
It can be! If you've got a crack legal team at your disposal, you can absolutely sue over insurance denials that put your health at risk. The problem is that most folks who need an insurance plan that regularly denies them also don't have the money to afford a crack legal team to sue the insurer. (If you're that wealthy, typically you would just have a private physician that you're paying directly, who has no problems treating you promptly because that's what they're paid to do.)
This is representative of a general problem with the legal system today. It's too expensive, and operates too slowly. When the economics of cheating people were that you might be able to cheat 10 people before you pick on the wrong guy who has a lawyer that puts you out of business, you have an incentive to follow through on your contracts and do what you say you'll do. When the economics became that you can cheat 10 million people before you pick on the wrong guy who sues you, it becomes rational to take the money from those 10M people and use it to outspend the guy who sues you, or at least just pay him off so he goes away. And so our western notions of democracy and contract law get subsumed into a feudal system where only big corporations get protection of law, and you must join the local protection racket to slot into that system.
The problem is that when such things happens, insurers have said - and won - in Court with:
"We are not denying or delaying care for our customer. We are, instead, only noting that we are not going to be the Responsible Party for paying for it. They are, as they have been all along, free to get the care they believe they need and pay for it themselves."
This brought to you by the same legal scholars that brought you theories such as "Everyone knows 'own' doesn't mean 'own'" and "It's okay to give the judge hearing your case tons of money because that's just gifts between friends as long as you don't explicitly say it's a bribe". Our legal system seems to be based around deciding on the outcome you want regardless of rationality or the law, talking nonsense long enough that it seems like there's intractable disagreement and then declaring your solution to be the common-sense middle ground.
but do you have any evidence beyond intuition that those denials differ significantly in reversal rate? one would guess that things that are never going to be covered get denied and then never appealed but one would also guess that things that are never going to be covered don't get submitted in the first place. assuming that the rate of legitimate denials is higher among those claims never appealed, what rate of illegitimate denials is acceptable? why would denying even one person care that they're contractually entitled to receive be okay? why shouldn't insurance companies have to do what they promise to do and accept money for?
This is pretty standard procedure in a lot of industries:
Health insurance will often initially deny coverage, either in the pre-approval or when you get the bill, but if you firmly follow up and hold their feet to the policy they will reverse that.
Even if you're uninsured, healthcare providers will usually settle medical debt for about 10c on the dollar if you threaten bankruptcy.
Home/auto insurance will often give you a black hole for claims; the adjuster won't get back to you for months at a time. But if you keep calling them enough to be annoying, they will usually eventually pay out.
Contractors will often fail to fix shoddy workmanship until you threaten to report them to the local licensing board.
Cops will often ticket you, but a surprising number of tickets get reversed if you contest them in court, oftentimes because the cop doesn't even show up. One of my friend's parents in high school vowed never to take a speeding ticket lying down; he was 5-0 on contesting them.
The IRS will come at you with the interpretation of tax laws that is most favorable to them given the data they don't have available, particularly if you are high-income. But if you actually know the laws and can show hard data (statements/receipts), you can usually get the bill they claim you owe reduced by 80%+ or even to $0.
Colleges will often increase their financial aid packages by thousands of dollars if you have a competing acceptance and are like "Well, I would love to attend your school, but financially it's hard for me to justify paying $X more than this other school I got into."
Companies will often increase their compensation offers significantly, sometimes by hundreds of thousands of dollars, if you turn down their offer.
It's all negotiation. They put forth an initial low-ball offer because most people accept it. If you make it clear that you are one of the folks who will make a stink about it, they'll often increase their offer significantly to get you to go away.
I think the law needs to change. Statutory damages for any initial refusal that is later overturned, whether by a court or by the company themselves. Treat it as breach of contract.
This is is to change the economics so that there is a cost to a business for automatically denying, just as there is a cost to the claimant when the business automatically denies.
> Home/auto insurance will often give you a black hole for claims; the adjuster won't get back to you for months at a time. But if you keep calling them enough to be annoying, they will usually eventually pay out.
Fortunately I live in a more reasonable country, where I don't have to keep chasing them; I can simply claim through the court system instead. I think the system works here - I haven't heard that to be a problem here.
I would agree with this solution, and also think that these other reforms to the legal system are necessary:
1.) The cost of the court system needs to go way down. It's not okay to have justice be a luxury good; every citizen needs to have a way of adjudicating and enforcing their rights.
2.) Laws need to be enforced uniformly. Right now the usual outcome for the squeaky wheel that files a lawsuit is that they get paid out in a decent settlement, the case is dropped, and the corporation goes right on screwing everybody else who doesn't bother to enforce their rights. Or it becomes a class-action lawsuit where the lawyers get $40M, the plaintiff gets $10M, and every other member of the class gets a check for $100. If a judgment for a class-action lawsuit is $10M, every member of the class should get $10M, not just the plaintiff. If this bankrupts the corporation, so be it: maybe their business practices were invalid to begin with.
3.) Relatedly, laws that are never enforced should fall off the books so we don't get this kind of "regulation by enforcement" that can be used to arbitrarily punish people, as well as wholesale shifts in the legal regime based on which party is in power.
4.) It should be easier to collect on judgments. It can take years for a judgment or settlement to clear your bank account in the U.S. Some people don't have years, particularly those with health conditions or living on the edge of poverty.
This is reality, but it is a bad reality. Nowadays it seems I find myself constantly having to "chase" things that I never had to in the past, just to get them resolved in a way that is not totally screwing me over. Every time some company fucks something up (always in their favor), it turns into a letter sitting on my desk that I have to call someone about, navigate through phone trees, submit this info, confirm that info, and remind over and over until it gets resolved. Particularly around any kind of insurance or any case where a company owes you money. Nobody pays unless you hound them relentlessly.
A consequence of this approach is that the insurance industry might as well not exist as far as I am concerned; they have poisoned their entire value proposition. I will not voluntarily do business with people who plan to screw me over.
A rule of thumb is that it's never worth taking out insurance on something that you can afford to replace in full yourself.
Note though that in many cases, insurance is mandated by law. In many states you have to have auto insurance. If you have a mortgage you usually have to have home insurance. The cost of medical treatment is such that a single accident can cost more than your lifetime earnings, essentially forcing an automatic bankruptcy. Indeed, the reason for the auto and home insurance mandates is often to pay for liability coverage in case you get sued for somebody else's medical treatment.
Given the dealings that I've had with the insurance industry, it seems that many companies realize that their function is just to tick the legal box. They have skeleton or nonexistent claims-handling departments that employees are frequently laid off from. The goal is to slow-walk any claims past the statute of limitations, so that nobody gets paid out anyway, but they can continue to collect the premiums because the government requires that everyone have insurance. (But then another phenomena is that people are increasingly ignoring the government too, such that they now offer "uninsured motorist coverage" to make up for cases where you're hit and hurt by someone who illegally doesn't have insurance.)
You're forgetting that all of this has an opportunity cost that most people simply do not have the ability to meet. Spending dozens or even hundreds of hours following up with companies that have a lot more capital, manpower and incentive to screw you over is not something the average person is either willing or able to do.
That seems a very USA problem. It seems a very adversarial society.
Are the ads for layers on buses and benches for real or just a TV trope? I have never seen anything like that in Europe...
Most of the listed problems are issues of incentives, and those are true everywhere. Insurance companies are always going to be reluctant to pay.
That there are no billboard ads for personal injury lawyers, clearly doesn't imply injury lawsuits aren't occurring.
Yes. In California 75% or more of the roadside billboards and bus ads are for lawyers. Typically injury lawyers. They have their own slogans and jingles.
In the Bay Area they tend to be for AI companies, though I'm pretty sure I've seen at least one for an AI lawyer. (Meaning a general-practice lawyer that is actually a datacenter, not a human lawyer who practices AI law.)
It's actually kinda fun to look at the public transportation ads and see what they say about each major metro area. In the Bay Area most are for enterprise software vendors. In Boston most were employment ads with some obscure scientific or mathematical puzzle where if you solved it, it redirected to a biotech or software company's jobs page. In Baltimore, it was mostly for bail bonds.
This is time consuming and emotionally costly. A big waste of resources.
The difference here is that oftentimes your situation can markedly deteriorate, sometimes irreversibly, as a result of that denial. And the "make a stink" can come at a time you're least equipped to deal with it.
> It's all negotiation. They put forth an initial low-ball offer because most people accept it.
And that's the problem. People having to make a stink because insurers are doing things that are in contradiction to the policy they wrote, if not the law, because private enterprise wants more money.
Private enterprise that has simultaneously almost singlehandedly caused the skyrocketing of medical costs, because the only way to make more money when your profits are regulated is to increase costs, and nobody except the consumer/patient is incentivized to do anything about it, quite the opposite - they're entirely happy to go along with it. And then insurers will stand up in Court and say "Oh, we're not denying care to our customer, we're just saying we won't pay for it. They're free to pay for it out of pocket." My old boss would have received a $1.8M bill for his daughter's care, born at 33 weeks. A coworker of mine had to raise a substantial portion of an expected $1.25M bill for a lung transplant for her son. My kidney stone would have cost $70,000 to have not been resolved (they went in, found infection, retreated and gave me IV antibiotics instead, and revisited the issue two weeks later, which had its own separate bill). My ENT had to put me on two expensive and useless nasal sprays for months so that when he recommended deviated septum surgery for an effectively blocked nostril (90%+ deviation) that insurance wouldn't deny it because (gasp, shock, horror) nasal sprays don't realign or open up cartilage.
Exactly. You shouldn't have to lift a finger to negotiate with a company where there is a written agreement that they owe you money or that you are entitled to a claim or similar.
This whole "you have to haggle for everything" culture we're putting together stinks.
An individual who makes a false insurance claim is committing a felony, but a manager who knowingly denies thousands of valid claims is rewarded with bonuses and promotions.
CEOs who who structures the company to denies as many valid claims as possible are handsomely rewarded by Wall Street for increasing margins.
Things really need to change at a core level in America.
Health insurance should be automatically approved and then prosecuted if there is a suspicion of fraud. Kind of like DMCA works.
There's a pretty strong selection bias here, where you only challenge a denial if it's likely to be overturned.
Cus their goal is to make it really difficult to fight claim denials, so people who don't have the time or energy to, don't fight it.
> so people who don't have the time or energy to
For example, people who are sick, ill, or injured...
>Few patients appeal when insurers decline to pay for their care. Many don’t even know they can. But new data show that when they do, they frequently win — in some plans, nine out of 10 times.
If 90% of denials that are challenged end up being reversed, and the delay in delivering the care that the insurer contractually agreed to deliver is deleterious to the patient's overall health and leads to prolonged suffering, why is this not a cause of action? Until there is some sort of downside introduced, the "deny til they die" health insurance model is going to continue to thrive at the expense of people not getting the care they paid for and are entitled to.
It can be! If you've got a crack legal team at your disposal, you can absolutely sue over insurance denials that put your health at risk. The problem is that most folks who need an insurance plan that regularly denies them also don't have the money to afford a crack legal team to sue the insurer. (If you're that wealthy, typically you would just have a private physician that you're paying directly, who has no problems treating you promptly because that's what they're paid to do.)
This is representative of a general problem with the legal system today. It's too expensive, and operates too slowly. When the economics of cheating people were that you might be able to cheat 10 people before you pick on the wrong guy who has a lawyer that puts you out of business, you have an incentive to follow through on your contracts and do what you say you'll do. When the economics became that you can cheat 10 million people before you pick on the wrong guy who sues you, it becomes rational to take the money from those 10M people and use it to outspend the guy who sues you, or at least just pay him off so he goes away. And so our western notions of democracy and contract law get subsumed into a feudal system where only big corporations get protection of law, and you must join the local protection racket to slot into that system.
The problem is that when such things happens, insurers have said - and won - in Court with:
"We are not denying or delaying care for our customer. We are, instead, only noting that we are not going to be the Responsible Party for paying for it. They are, as they have been all along, free to get the care they believe they need and pay for it themselves."
This brought to you by the same legal scholars that brought you theories such as "Everyone knows 'own' doesn't mean 'own'" and "It's okay to give the judge hearing your case tons of money because that's just gifts between friends as long as you don't explicitly say it's a bribe". Our legal system seems to be based around deciding on the outcome you want regardless of rationality or the law, talking nonsense long enough that it seems like there's intractable disagreement and then declaring your solution to be the common-sense middle ground.
They don't count the claims that are never fought in the first place. Which i would wager is the majority.
but do you have any evidence beyond intuition that those denials differ significantly in reversal rate? one would guess that things that are never going to be covered get denied and then never appealed but one would also guess that things that are never going to be covered don't get submitted in the first place. assuming that the rate of legitimate denials is higher among those claims never appealed, what rate of illegitimate denials is acceptable? why would denying even one person care that they're contractually entitled to receive be okay? why shouldn't insurance companies have to do what they promise to do and accept money for?
https://archive.today/zYeNB
Seems broken, doesn't contain the entire article text.
Gift link: https://www.bloomberg.com/news/features/2026-09-14/about-hal...
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