Are You Insured... Enough?

Insurance is a means of protection from financial loss. It is a form of risk management primarily used to ‘hedge against the risk’ of a contingent, uncertain loss.

An insurer, insurance company, or insurance carrier provides the insurance. A person who buys insurance is known as an insured or policyholder. The insurance transaction involves the insured ‘assuming a guaranteed’ and known relatively small loss in the form of payment to the insurer in exchange for the insurer’s ‘promise to compensate’ the insured in the event of a covered loss. The loss may or may not be financial, but it must be reducible to financial terms, and must involve something in which the insured has an insurable interest established by ownership, possession, or preexisting relationship.

The insured receives a contract, called the insurance policy, which details the conditions and circumstances under which the insured will be financially compensated. The amount of money charged by the insurer to the insured for the coverage set forth in the insurance policy is called the ‘premium’. If the insured experiences a loss that is potentially covered by the insurance policy, the insured submits a claim to the insurer for processing by a ‘claims adjuster’.

There are all types of insurance:

• Auto insurance • Gap insurance • Health insurance • Income protection insurance • Casualty insurance • Life insurance • Burial insurance • Property insurance • Liability insurance • Credit insurance

You can insure just about anything. You can insure your pet. You can insure your hairdo. You can insure your shoes. You can’t insure your faith?

Health insurance policies cover the cost of medical treatments. Dental insurance, like medical insurance, protects policyholders for dental costs. In most developed countries, all citizens receive some health coverage from their governments, paid for by taxation. In most countries, health insurance is often part of an employer's benefits.

Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care and health system expenses, among a targeted group, an insurer can develop a routine finance structure, such as a monthly ‘premium or payroll tax’, to ensure that money is available to pay for the health care benefits specified in the insurance agreement. The benefit is administered by a central organization such as a government agency, private (for-profit) business, or not-for-profit entity. Health insurance includes claims for injury, sickness, accident, medical expense, disability, or accidental death and dismemberment.

Health maintenance organizations (HMO) tended to use the term “health plan”, while commercial insurance companies used the term “health insurance”. A “health plan” can also refer to a subscription-based medical care arrangement offered through HMOs, preferred provider organizations, or point-of-service plans. These plans are similar to pre-paid dental, pre-paid legal, and pre-paid vision plans.

Pre-paid health plans typically pay for a ‘fixed number of services’ (for example: $300 in preventive care, a certain number of days of hospice care or care in a skilled nursing facility, a fixed number of home health visits, a fixed number of spinal manipulation charges, etc.). The services offered are usually ‘at the discretion’ of a utilization review nurse who is often contracted through the managed care entity providing the subscription health plan. This determination may be made either prior to or after hospital admission (concurrent utilization review).

There are different options available to both employers and employees. There are different types of plans, including health savings accounts and plans with a high or low deductible. The plans that have the high deductibles typically cost the employee less for the monthly premiums, but the part they pay for each time they use their insurance, as well as the overall deductible before the insurance covers anything is much higher. These types of plans are good for the people who rarely go to the doctor and need little health care. The lower deductible plans are typically more expensive, however, they save the employee from having to spend a lot of money out-of-pocket for services and treatment.

The recent trend for employers is to offer the high deductible plans, called ‘consumer-driven healthcare’ plans, because it costs them less overall for the care their employees need, but it is a lower monthly premium for the employees.

‘Comprehensive’ health insurance pays a percentage of the cost of hospital and physician charges after a deductible or co-pay is met by the insured. These plans are generally expensive because of the high potential benefit payout — $1,000,000 to $5,000,000 is common — and because of the vast array of covered benefits.

‘Scheduled’ health insurance plans are not meant to replace a traditional comprehensive health insurance plans and are more of a basic policy providing access to day-to-day health care such as going to the doctor or getting a prescription drug. These plans have taken the name “mini-med plans” or “association” plans. The term “association” is because they require ‘membership in an association’ (like AARP or Health Care Credit Union Association) that must exist for some other purpose than to sell insurance.  These plans may provide benefits for hospitalization and surgical, but these benefits will be limited. Scheduled plans are not meant to be effective for catastrophic events. These plans cost much less than comprehensive health insurance. They generally pay limited benefits amounts directly to the service provider, and payments are based upon the plan’s “schedule of benefits”.

Getting confused yet?

‘Health care’ or ‘healthcare’ is the maintenance or improvement of health via the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in human beings. ‘Health care’ is delivered the insured by allied health professions, chiropractic, physicians, physician associates, dentistry, midwifery, nursing, medicine, optometry, pharmacy, psychology, and other health professions. It includes the work done in providing primary care, secondary care, and tertiary care, as well as in public health.

According to the World Health Organization (WHO), a well-functioning health care system requires a robust financing mechanism; a well-trained and adequately-paid workforce; reliable information on which to base decisions and policies; and well maintained health facilities and logistics to deliver quality medicines and technologies.

Got it so far?

You choose a provider of health insurance and choose the options that fit your needs and your budget. You pay your monthly premiums and hope you don’t get sick or hurt.

If you do get sick or hurt, you turn to your health insurance provider to assist you in paying the cost from your previous premium payments and agreed upon co-pay.

Sound good so far?

Then your doctor or physician or whatever kind of medical practitioner suggest a procedure not covered under your health insurance contract. Out of pocket expense that was not expected.

Is it a toss of a coin in a life or death experiment to survive?

The government now wants to step in and save you from the fear of pain without any medical assistance and as we have done since the civil war we expect to be taken care of, but remember our medical providers are a market based industry based on making a profit whether you feel better or not.

Socialism is a range of economic and social systems characterized by social ownership and democratic control of the means of production; as well as the political ideologies, theories, and movements that aim to establish them. Social ownership may refer to forms of public, collective, or cooperative ownership; to citizen ownership of equity; or to any combination of these.

Democracy is a system of government in which the citizens exercise power directly or elect representatives from among themselves to form a governing body, such as a parliament. Democracy is sometimes referred to as “rule of the majority”. Democracy contrasts with forms of government where an individual, as in an absolute monarchy, either holds power or where power is held by a small number of individuals, as in an oligarchy.

A Republic is a form of government in which the country is considered a “public matter” – not the private concern or property of the rulers – and where offices of state are elected or appointed, rather than inherited. It is a government where the head of state is not a monarch and government leaders exercise power according to the rule of law.

Republics became more common in the Western world starting in the late 18th century, eventually displacing absolute monarchy as the most common form of government in Europe. In modern republics, the executive is legitimized both by a constitution and by popular suffrage. Most often a republic is a single sovereign state, but there are also sub-sovereign state entities that are referred to as republics, or that have governments that are described as ‘republican’ in nature. For instance, Article IV of the United States Constitution “guarantee[s] to every State in this Union a Republican form of Government”.

Enough of political science, you have a representative telling you that this is the kind of health insurance that is approved by your government. A variety of providers are more than happy to take your money with promises of happiness and no worries until….

Old Doc Page used to come around to the house when I was blowing chunks into a trashcan and my mom and dad didn’t know what to do but put a cool wet washcloth on my forehead and give me ginger ale. Old Doc Page would read the thermometer and say, “Take two aspirin and call me in the morning.” There were no scheduled visits to his office to check for preventative signs of unhealthy habits.

Before Old Doc Page it was just grandma and aunts and uncles and the church elders who stepped in when your parents were overwhelmed with illness in the family. These were the same folks who dug the hole to place the body in.

You make your decision and fret on if you have enough insurance. There are lots of options and they are changing everyday. Alone the pharmaceutical industry is coming out with plethoric amounts of variables to purchase and place in your body to see if they make any difference.

Unfortunately things happen to us whether willingly or by fate and suddenly we must deal with sickness or injury. The old idea of ‘shake it off and rub some dirt in it’ has transformed to ‘who is going to take care of me?’

If instead of using your local doc-in-a-box for visits to check all the internal and external problems, the Emergency Room is your physician of choice. Unless you are rolled in on a gurney with trauma (you know that icky stuff) you sign in and wait for the next number to be called. No matter which insurance policy you have or how much you get frustrated you have to wait your turn.

Everyday we come up with a new description for all our maladies and the health care professionals must find a way to sooth us. They may not be able to cure us but they can dope us up and poke us and pump us and charge us to increase their knowledge using us as genie pigs.

I pity those poor folks who really need the care and appreciate those marvelous folks who run to help in disasters without asking for their identification or insurance policy. I also wonder about all the government’s warnings about how we eat and what we eat and how we sleep and our lack of exercise goes unnoticed like the speed limit and picking up after your dog poops.

I have gone for years without the safety net of health insurance. It is a crapshoot. Did I follow the healthy regiment of three meals a day, exercise and plenty of sleep? Was it a sane decision or a necessary?

Until the government or whatever powerful being declares that everyone can go to any medical provider and get the best care without restrictions, then I’ll be comfortable. In the meantime, I’ll try and eat more greens than ice cream, sleep before 2AM and wake before noon, take a daily ride and stay hydrated. I’m insured.

It may not be what Old Doc Page would have prescribed but so far it has work for me. So far?