Insurance companies take away drug choices

| 27/09/2018

Ask Auntie, CNS Local Life, Caymanian statusHow can a doctor prescribe a medication to treat a chronic illness and an insurer then decide they know better than the doctor and choose not to cover it? What is even more infuriating is the Big Pharma alternative is three times more expensive than cannabis oil and has so many side effects yet they have no problem covering this? Where is the logic?

Where is the protection from government here? Someone needs to step in and make these insurance companies pay!

Auntie’s answer: A warning before I respond: You have touched a huge nerve for me and I will try not to answer in all caps, but feel free to picture my words being yelled.

Of course, you are absolutely right to be infuriated. Some nameless person at an insurance company can wield absolute power in determining whether a medication will be covered by the holder’s policy. While there are avenues to appeal the decision, it often comes down to the fortitude and determination of your doctor whether you will win that battle.

However, based on experience and stories I have heard from other people, I feel safe to say that insurance companies usually do not change decisions on coverage very often.

Unfortunately, there really is no legal protection for this situation. You can contact the Health Insurance Commission (here is the website) for help/advice, but if the insurance company in question is following the law, there is not much that can be done.

Sadly, the lack of coverage for certain medications, especially expensive new drugs that fall into the category of biologics (those that usually end in “mab” for monoclonal antibodies) that can treat a range of diseases/conditions seems to be standard practice. The same holds for medications that are considered “off label”, meaning they are accepted for certain diseases but may hold promise for others that are not included in the list the drug is normally used for.

And I haven’t even touched on the issue of supposedly “group coverage” that is anything but. In the US, for example, insurance companies can have millions of clients, enabling a large pool of shared risk which can keep premiums relatively manageable.

Here in Cayman, however, do not be fooled by the term “group”. While a company can be considered a group as far as the plan it offers to employees, the size of the pool covered is limited to the number of staff involved. So, if you are one of, say, 50 people in the so-called group plan, the supposedly shared risk actually means if even one employee suffers catastrophic medical bills the premium for everyone could go up dramatically.

That is why there have been calls for a national plan involving a single-payer system where the risk is truly shared among the entire population (including those who are young and healthy), which could maintain reasonable premiums.

I believe the only way forward is to make our legislators deal with this issue by changing the law. Approach your MLA to find out his or her stance on insurance and ideas for improving the system. Tell them how you feel about this issue. There has been lots of talk over the years but so far nothing has changed. If your MLA does nothing, vote him or her out in the next election.

Everyone should have the right to affordable health care. No one should face the choice of either bankruptcy or life-saving or quality-of-life-maintaining medical help.

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Category: Ask Auntie, Health Insurance Questions

Comments (25)

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  1. Anonymous says:

    The moaners on here are the same sort of people who moan that their insurance costs are too high. SMH, SMH.

  2. Legal genocide says:

    Doctors, health insurance, what a mess! The way I see it is that their motto is to ” keep em sick” . If not, there is no profit and that is the reason for the Doctors, insurance companies, Big Pharma and Govt will continue to perpetrate the lies. The answer is diet or pills. The Doctors won’t tell you this! That’s why Doctors don’t practice functional medicine , only treating the symptoms not the cause. Got to keep you sick or no profits. I could expand on all of this, but you get it.
    Your frustration is well noted CNS.

    • Anonymous says:

      CNS I appreciate that you allow pretty much everyone to express their opinion on here, and this openness keeps me commenting, but as a med student I CANNOT understand why you’d allow this idiot to claim that Doctors want to keep us sick.

      Doctors go into a ridiculous amount of debt, spend a literal decade training for their position, swear an oath to do no harm, are required to give patients 24 hours of attention at some point, and yet they think they “have to keep you sick”.

      • Anonymous says:

        Your intentions might be good but THE WHOLE SYSTEM is designed to keep people sick and on medications for life.

  3. Anonymous says:

    Well maybe if everyone is happy to double their insurance premiums we can get the medicines we want even if there is not a medical consensus on it being a cost effective treatment. Happy to double your premium?

  4. Anonymous says:

    Insurance companies can quickly reference large scale scientific studies that meet specific endpoints that are currently accepted by the scientific community. Canabis is just not there yet. Whether it works or not, it’s a liability in the end. Then there’s the issue of it being taboo, an entirely different hurdle.
    Also know there’s a lot of discounting and kickbacks taking place here that patients and doctors know nothing about. I know that may not sound “right”, but this be business. There’s a lot (too many) moving parts taking place between a physicians prescription and the patients first dose. In most US states, pharmacy’s can change a branded prescribed drug to generic at their level, at their discretion with no consent, and it’s perfectly legal. All of this has the potential to lessen a patient’s response to a disease, as well degrade a drug manufacturers desire to research newer products. In one sense it is good, but in another it’s bad…

    • Anonymous says:

      Typical private sector incompetence. Dont worry the civil service will sort this mess out.

      You desrve better from the private sector insurance companies

    • Anonymous says:

      THC and CBD is schedule 1, but when the FDA allowed it to be extracted from the cannabis plant, then the factory adds ethanol, artificial strawberry flavor, and sucralose, suddenly it’s a legal prescription drug for epilepsy and is schedule 5.

      Your argument is invalid.

      • Anonymous says:

        I’m not sure who you’re directing your comments to, but this is the way insurance companies review. And there is no argument. No one cares about strawberry flavor or anything else. The fact remains is they don’t have the indication. Do you need some justification to look that up as well? Please don’t spew your ignorance

      • Anonymous says:

        There is no argument fool
        Go stick your head back in the sand

  5. Anonymous says:

    The bigger picture is lost in many of the comments on here. Face to face a doctor tends to over prescribe to appease the patient either into terms of prescribing at all or the costs effectiveness of the prescription in question. Multiplied over a patient population this tendency would be a huge problem for the costs of health care but for the ability of insurance companies in a private model or regulators in a public model stepping in and rationalising the genetic decision making processes. The people moaning in this thread are no doubt the type that moan about the cost of their insurance too. Talk about having their cake and eating it.

  6. Anonymous says:

    The world is a crappy place I have to admit. Corporations rule the world now and want us all to die.

    • Anonymous says:

      They want us sick and unhappy so we have as many reasons as possible to buy things and always be in debt.

  7. CB4 says:

    Its time for the Govt to remove the legal requirement for residents to have private health insurance.

    Its time for private insurance companies to go back to having to sell their empty promises vs having their sales/income guaranteed by our Govt.

    HIC is useless and supports the insurance companies, not the public.

  8. nickcayman says:

    Insurance Monopolistic Cartel would be a better term to use in the Cayman Islands.

    Change can be brought about if the citizens feel strongly enough about the situation and are willing to speak out public ally.

    Since we are a British Colony ask yourselves why we do not have the National Health Service (NHS) running the entire health services, and paying for it, as happens in the UK. We are citizens are we not? Just imagine the immense buying power of the NHS? We could be getting our medications 80%+ cheaper…

    • Ron Ebanks says:

      I think the broader question that should be asked to your issue , who are involved in the racket to why certain prescription drugs are not covered by your insurance policy . You will be surprised . But like Auntie said , call you district MLA and let him/her hear your concerns .

  9. Anonymous says:

    I like drugs

  10. Anonymous says:

    Insurance companies have their cake and eat it here all as usual. I’m gobsmacked as to why our HIC idly sit by and watch the tail wag the dog. This is a sickening situation especially for those who can’t fund their own med purchases. I truly feel for your plight and try to find natural remedies where possible, but that usually means paying your own way. Ironically, insurance companies are more than willing to pay for generous prescriptions of opiates and antibiotics.

    One could argue that this is an infringement on the quality of human life. Either way the whole system needs to change and the only way that’s going to happen is go through a tedious due process like Mr. Warren endured. Other than that, the next election might offer a chance to rein in insurance companies and force them to do right by the people. They sure as hell can afford it!

  11. Anonymous says:

    When it comes to chronic diseases, allopatic medicine is useless. You either have an anxiety or it is all in your head. Antidepressants seem to only remedy doctors offer these days. By the way anxiety is a symptom, a signal, not a mental disease. Two hundred years ago doctors were more helpful. They knew that Balneo clinics were very effective in treating chronic diseases. Today, in many European countries one month treatment course is covered by many insurances. Hemp and Marijuana remedies were very helpful for numerous chronic conditions and were sold without prescription. Even cocaine was a medicine. Castor oil packs were used for pain and inflammation of any kind, bones or soft tissues. Try and you will be amazed. Today, external counterpulsation therapy could replace a bypass surgery and it brings back to life stroke victims. In the USA, it is covered by most insurances, but hardly any doctor knows about it. LDN is very effective for a long list of health issues from cancer to neurological degeneration, but doctors know nothing about it and insurance won’t pay for it. This pisses me off a big deal. I had to order it from Singapore for my mother, as NO doctors would prescribe it. In-home legs compression pumps are not just for lymphedema, but also for poor circulation, low blood pressure etc. I bet you never heard about it. Luckily you can buy it on Amazon, but it is expensive. Improved blood supply to the heart and brain can cure many diseases. Many insurances would pay if only your doctor knew about it. (I bought AirRelax for my mom.)
    So why doctors won’t even mention these very effective modalities for treating chronic conditions and insurances won’t pay for it? We live in a crazy time when insurance will pay for medicine that further destroys your body and refuse to cover what works with no side effects. The answer is- they want you to remain sick. “Managing” a disease is a very lucrative business. Cutting out your gallbladder is a very lucrative business. One month in Karlovi Vari and you will forget about your gallbladder for many years. Cutting out your uterus is a very lucrative business. Again, endometriosis is a treatable condition in most cases.
    So your life and health are literally in your own hands. Either doctor won’t treat you for the lack of knowledge or insurance won’t pay.
    Modern medicine is very good during an acute emergency. They would glue all your pieces back in place and let you out to live the life of chronic pain and suffering.
    There’s a documentary on Netflix, The bleeding edge. You might want to watch.

  12. Anonymous says:

    There is high variance in Health Care Providers and coverage on island. Some won’t insure a group if there are staff with prior histories of certain cancers. They are heartless bastards that query everything from routine doctor checkups, to dental cleanings. I often have to settle disputed insurer co-pay expenses from previous visits when arriving at an appointment.

  13. Anonymous says:

    Cannabis saved my life. I used to be suicidal, and when I admitted that to a close friend, they brewed me a tea from the plant. Now I drink a cup on the weekends for a regular reminder on how to smile, laugh with someone, and eat.

    Sad, because when I tried anti-depressants, I hated those pills so much. Even more sad, I could snort a line of coke tonight and be clean a few days from now. If my insurance company drug tests me and only finds cannabis a month from now, I lose my coverage.

  14. Anonymous says:

    I am also on cannabis oil for a chronic auto-immune disease and my options are…

    1. Take $1,750 a month biologic medicine (loaded with side effects) which insurance will cover 80/20 meaning $350 a month co-pay.
    2. Pay $400 a month for NATURAL cannabis oil which works and has ZERO side effects, but isn’t covered by insurance leaving me with a huge financial burden.
    3. Do nothing and let the disease destroy my health

    If the government would step in and do something about the insurance cartels on this island that would be great!

  15. Anon says:

    Well said CNS!