The troubled reality of medical insurance

 For most policyholders, the inner workings of their health insurer are a black box: Requests to cover treatment or pay claims go in, and approvals or rejections are spit out. The pivotal gatekeepers inside the box are medical directors. They can, without ever seeing a patient, overrule the judgment of the doctor who did and deny payment for a recommended procedure, test or medicine.

Insurers say medical directors steer patients away from unnecessary or risky care and expensive treatments for which there are less costly, equally effective alternatives. Patients and their physicians complain that insurance company doctors routinely, and wrongly, deny payment for critical lifesaving treatments because they are expensive.  The stakes are high: A refusal to pay for treatment can drive families into bankruptcy. Some patients, facing the cost, forgo care altogether. And a single medical director can rule on 10,000 cases a year, according to court testimony in a case involving Aetna. Some Cigna doctors have ruled on more than 10,000 cases in a month without opening the patient file, as ProPublica and The Capitol Forum have reported.