A Boring Dystopia

Let’s say you get diagnosed with a treatable autoimmune disorder. Treatment isn’t cheap, so usually someone who recently got diagnosed and referred to a specialist to perform care will find that their insurance denied approval for prescription of medications and supplies needed.

The insurance companies will want the doctor to re-submit while providing documentation of the diagnosis (as proof) and an outline of the treatment plan. The insurance company can say “your plan states six months of injections but we will only approve for three.” At that point, the patient is stuck with a three-month plan because the cost of treatment is too much to pay out of pocket and the doctor won’t go forward with a six-month plan unless the patient pays in advance for the three months that wouldn’t be covered.

Another example is rare disorders where the medication may cost hundreds of thousands of dollars. Insurance may decide the cost is too high and deny coverage for the prescription.

Finally, there are instances where more common issues (such as diabetes) may have the insurance artificially limit how many doses of a drug they decide to cover. If a person has a special case (like needing to take twice the amount due to tolerance or it being based on the person’s weight), insurance may deny it because it exceeds what they believe the average person should need.

All of these are examples where someone is stuck waiting for what is essentially life-saving medication just because insurance doesn’t want to pay out, or doesn’t care that you have a special scenario that requires some exceptions for it to work properly.