Sunday, November 23, 1997
Insurers stymieing important
treatment of obesity
We allow these folks to be
treated as second-class members of our society because of the incorrect and
prejudicial bias that will power or self-discipline alone can cure severe
obesity.
By Barry L. Fisher
Special to the Review-Journal
John McSherry, a major league baseball umpire, collapsed and died behind
home plate while working a game. This event was witnessed by many Nevadans who
were watching the game on television. His fatal heart attack was caused by
morbid obesity from which he had suffered for many years.
In 1985, the National Institute of Health officially described morbid
obesity as a chronic disease. In 1991, it endorsed surgery as a reasonable
alternative to medical therapy. In 1992 it confirmed the ineffectiveness of
dietary approaches in this group of people. In 1993, an article in the Journal
of the American Medical Association confirmed that more than 300,000 people in
the United States each year die as a result of medical conditions directly
related to obesity.
Morbid obesity is a chronic disease and is a major killer of young to
middle-age people in our society. The medical problems that are associated with
morbid obesity include high blood pressure, diabetes, heartburn, apnea,
shortness of breath, high cholesterol and heart disease, to name a few. Many
patients who undergo specific surgery achieve long-term success in significant
weight loss, and concomitant improvement in the same associated conditions that
can lead to early death.
Although many health insurance plans, HMO's and managed-care entities
understand this and are willing to cover obesity surgery, others have
specifically excluded benefits for weight management or the complications of
medical or surgical weight management therapy. Others profess coverage, but
routinely deny benefits -- many such denials are based on incorrect information
and bias, despite literature attesting to the positive effects of the weight
loss resulting from such surgery. None of these companies employs specialists
with expertise in surgical care of the super-obese to adjudicate these denial
decisions.
The 1997 Legislature passed Assembly Bill 169. It restores many rights of
appeal and provides recourse to many Nevadans who have been denied payment for
appropriate medical care. This bill specifies that a specialist review denial
decisions. However, many Nevadans are exempt from the provisions of this
legislation due to a 1974 federal law called the Employment Retirement Insurance
Security Act. It pre-empts all otherwise available remedies under state law. The
companies are, at most, only liable for the benefits they should have paid in
the first place, and -- in some limited circumstances -- attorney's fees. A
patient cannot sue for damages. Treatment is not given, because patients are not
inclined to litigate to obtain their benefits. Although insurers say their
financial decision to refuse coverage does not amount to practicing medicine,
the effect of their decisions determines whether or not most patients receive
the care they deserve.
Legislation is being introduced in Congress which would reinstate patient
rights to sue the insurers or managed-care plans for damages in the event they
are victims of improper claims-handling practices. It is called the Patient
Access to Responsible Care Act of 1997 and would revoke the protection for
insurers in the Employment Retirement Insurance Security Act. This bill will not
only help the morbidly obese obtain adequate treatment, but will also assist
many other people with health problems which are largely ignored by insurers.
The last vestige of socially acceptable discrimination in our society is
against our overweight citizens. We allow these folks to be treated as
second-class members of our society because of the incorrect and prejudicial
bias that will power or self-discipline alone can cure severe obesity. Patients
are discriminated against in the workplace, in the media and all types of social
situations -- and, tragically, also by their medical insurance carriers.
Discrimination against the morbidly obese in the workplace and by their
insurance carriers has to be eliminated. One avenue for accomplishing this is
the passage of the Norwood bill aiding morbidly obese patients denied
appropriate medical therapy on the part of their insurers. Care providers are
expected to accept responsibility for the medical decisions they make. When
insurers deny coverage for appropriate medical therapy, and this denial results
in the patient not receiving the medical therapy due to its high cost, and the
patient's inability to afford it, insurers should be held responsible.
We obtain insurance for the specific purpose of avoiding the devastating
financial impact of costly medical care that may have become unaffordable
despite being appropriate, indicated and life saving. It is time to hold all
insurance plans, their medical directors and executives, responsible for the
significant influence they exert on medical care and the suffering that may
result there from.
Dr. Barry
L. Fisher
is associate professor of surgery at the University of Nevada School of
Medicine. He writes from Reno.
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