[commanda]

My heart really goes out to you. Can you imagine replacing "autism" with "type 1 diabetes" in your story and any health insurance company acting that way? Unthinkable. I hope our culture gets to the point where it stops regarding some illnesses as unworthy of care.

[jetti]

Thank you. I am just baffled that an insurance company would pay for an unnecessary test instead of one that was deemed necessary. It seems completely contradictory to how they want to make money.

[Mz]

I am sorry about your situation but also curious as to how you think insurance companies work (if you don't mind me asking).

[jetti]

They negotiate a rate with providers in the network and pay out based on that. My point (and I don't think it was very clear) is that the system currently is set up (for at least that one company) so that if you don't have autism they will pay for the exam (which isn't cheap). Since there is no barrier to getting an exam, everybody could go and get the exam and for the majority of the people the insurance company would pay because they would (most likely) not be diagnosed with autism. The insurance company would pay out for all of these people for a useless test. Granted that this is only if a bunch of people wanted to waste their time and the time of the doctor(s), but it would still not be beneficial to the insurance company.

[Mz]

I am sorry, I don't really get what you think they do here. I worked for an insurance company for five years. The longer I worked there, the more policies I canceled. I am sure they won't go extinct just because I think what they do makes Darth Vader look warm and fuzzy, but their test policy is exactly in line with their goal: If you are diagnosed with autism, they don't want to cover treatment.

If you actually need treatment, they want to find a way to limit their liability. They want most people paying in to need little or nothing from them. They work like Las Vegas in that they design the game so the house wins much more often than it loses. It is the only way to pay the employees and keep the doors open. But at least Las Vegas has the redeeming value that you can view any small gambling losses as the cost of entertainment, as no different from buying, say, a movie ticket to be entertained for the evening.

Edit: But thank you for replying and have an upvote for indulging my curiosity.

Edit2: This is a criticism specifically of health and life insurance. Car insurance is another ball of wax and I think has more redeeming value.

[jetti]

"They want most people paying in to need little or nothing from them."

Exactly. I'm not conveying my thoughts very well. The way it is setup would allow people to treat the autism diagnosis exam as preventative care. If they know they don't have autism or suspect they don't, they can go get the exam done and insurance will cover it, even though there may have never been a valid reason for that person to take the exam. Granted, this isn't going to be something that many people (if anybody) would do for fun or to make the insurance company suffer, but it is an option the way they have it setup. I hope that makes more sense on my end.

[Mz]

The insurance company is well aware that few people will seek such an exam unless they have reason to suspect they have a problem. It is similar to the idea that you don't want to sell insurance specifically and only to cover pregnancy. Any woman looking to sign up for such coverage is extremely likely to be planning on getting pregnant.

Insurance is about risk management. In order to have "risk" there has to be chance. A lot of human behaviors are a choice, not a random roll of the dice. The insurance company is well acquainted with that fact.

I understand your framing, but, no, it doesn't really work that way. You just aren't going to have enough people who are sure they do not have autism decide to get tested for it for it to be a serious risk for the company. Their current policy covers their ass: if you get tested to confirm your diagnosis, you get to pay for the test and, apparently, volunteer to pay out of pocket for any further treatment related to your new diagnosis. They can merrily claim to cover the test if you do not need it because, in practice, the odds are really poor you won't get it if you do not need it.

I hope that is a little clearer from my end.