Insurance is a type of insurance coverage that covers or share the expenses associated
with health care such as medical and surgical expenses. According to Health
Insurance Association of America “health insurance is defined as a coverage
that provides for the payments of benefits as a result of sickness or injury.
It includes insurance for losses from accident, medical expenses, disability,
or accidental death and dismemberment.” (Caxton, G. 2002).  Health Insurance is a necessity in every
individual, it is important in so many several reasons nowadays and all of us
have a choice for quality and affordable health insurance. But in some point,
do we understood what is in our insurance health policy? Or is anybody else
totally confused by health insurance benefits? In this case, a retiree from
Richmond, Virginia Mr. Gerald Haeckel who is insured by Trigon Blue Cross /
Blue Shield questioned his insurer about the bill that he got from his wife lumpectomy
procedure done as outpatient surgery to remove a small breast tumor.

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Key Issues / Problems / Concern


Insurance is unlike any other insurance we buy, even after we pay premiums,
there still complicated and continuing cost. We pay premiums, a deductible, and
then most of the time we keep paying each time you go to the doctor, pharmacy,
or hospital. And when it comes to our health, it is not a matter of if you will
need that insurance, it is a matter of when we need it. And then it comes with
a billing statement. Mr. Haeckel had a problem with insurer-provider negotiated
discount with the bill that Trigon Blue Cross / Blue Shield. In Trigon’s
patient benefits billing statement indicate that the lumpectomy procedure done
with Mr. Haeckel’s wife had cost nine hundred fifty dollars ($950), 80% of it
will be paid by the insurer which is seven hundred sixty dollars ($760), and
20% will be shouldered by Mr. Haeckel which is one hundred ninety dollars
($190). But because of the “contractual adjustment” his one hundred ninety dollars
($190) copayment would exceed a third of the actual cost, instead of 20% called
for Mr. Haeckel healthcare policy’s patient responsibility section. A health
insurance copayment as we all know is a fixed amount established by insurance
plan for sharing the cost of health service between insurance plan and the
insurance customer, it’s a partnership between the consumers and insurer
offering policy. The problem is, when the insurer negotiates with the provider,
the customer is now out in the equation. The alleged scheme works when the
insurer negotiated a discount from the provider and does not pass any of the
savings on to its customer policyholders the copayments become higher of the
discounted actual bill and the insurer portion drops. The question is, did the
customer or Mr. Haeckel get benefited with the discount negation between the
insurer and the provider? Insurance plans are a partnership between the
consumers and the company offering the policy, copayment is a common form of
cost-sharing. Understanding how this system works helps you make a smart insurance
choices that suit both your health care needs and your budget but to do that
both parties will provide a clear understanding with the healthcare policy that
is why we called it cost-sharing.

            To this
day, consumers are now getting involved with their healthcare, but there is
still undisclosed discount raise questions about how accurate and true the
information provided by the insurers, providers, and the employers. Undeniably,
providers are contractually forbidden from disclosing the discounts and the
insurer argues that hiding discount is not widespread and notes that no court
has ruled for plaintiffs in a discount related case. The same goes with the
employer towards disclosing discount premium on the health benefits to their
employee. Indeed, how can a customer can take responsibility for his or her own
healthcare if there is no transparency in how the healthcare policy work? This
case brings us to ethical issue with the insurer and the provider to a customer.
A certain relationship, a person in a position of superior knowledge and
authority and in whom trust is respond has obligation and duties towards
others. Members should exercise reasonable care, skill and diligence in
proportion to the circumstances (Longest & Darr, 2014). They may not use their
position for personal gain and must act only in the best interest of your
customers or the people you are serving. Responsible marketing is an important.
If your insurer is focusing more on return on investment will view marketing as
a competition. To be responsible means tempering customer’s desires and
potential demand for service with objective judgements of its value and

/ Solution / Justification


delivery should improve through focusing on access and quality for health
insurance. Encourage providers to give care in outmost quality and cost-efficient.
There should be a support coordination between providers, insurers and customers.
And most of all to avoid confusion between everyone involved, insurer and
provider should provide accountability and transparency to your customers. It
is important nowadays to understand the basic of health insurance so you can
make the right decision for your family before you need it. That way, you can
focus more on healing when the time comes.

            Mr. Haeckel
and everyone one of us at some time in our life and often in many circumstance,
will need some kind of medical attention, treatment, and services. When medical
care is required, ideally the patient should be able to concentrate on getting
better towards healing, rather than focusing whether he or she got the money to
pay the bills. The administration, past and present are working on this through
health reform and insurance, The ACA introduced a number of provisions to
expand insurances coverage and improve insurance affordability and access, a
number of new insurance standards have been specified in terms of coverage. The
government must be on top of it and help consumers in helping them managing
their health through affordable health Insurance. Placing consumers at the
center of every healthcare operation and decision should be the goal. It is
possible that consumers advocacy could become more prominent in debates about
how healthcare financial is structured and it is possible that consumers voices
will more actively shape public policy. Consumers will still face important
personal decisions related to their healthcare insurance. They will need to decide
whether they are willing to pay more money or lower their out-of-pocket
spending, how much they will take in the form of large deductibles and copays.
Consumers are becoming involved in managing their healthcare and expenditures.

comes from the hard work and coordination of many individuals with knowledge
and motivation. Soon we will be part of it, one of the most important requirements
for an improved health care system is a well-motivated, well-trained and a
thoughtful leader. How good leadership is developed and emphasized the two
important traits, they are transparent and they hold themselves accountable. These
attributes are needed in the policy level and private sector corporate level.
They are needed to organize the voices of the consumers. (Jonas & Kovner,



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