Before health care became such a profit-driven industry, health care providers made decisions on what procedures or treatments are in the best interest of their patients. Now that insurance companies have invaded the industry in order to mine outrageous profits, things have become much more complicated. Insurance companies have created guidelines and policies regarding what treatments are "covered". While these guidelines and policies are generally reasonable, they fail to take into account the individual and penalize those who are not "normal" or "average". If a patient is outside the norm, the insurance company can then refuse coverage and increase their profits even if the individual genuinely requires the benefit.
For example, the MetLife Dental PPO covers tooth sealants. Tooth sealants are used to prevent tooth decay by filling in the deep grooves in molars where decay can form. MetLife's policy is that tooth sealants are covered for a "child who is under age 14". This is a reasonable policy since the "second" or "12-year" molars typically erupt at age 12. Sealants are not as effective if years of decay have occurred prior to applying the sealant. So their policy seems completely reasonable and fair.
However, a child of mine did not have their 12-year molars erupt until the age of 16. This is uncommon, but for whatever reason these molars stayed below the gums for much longer than the typical case. Within 6 months of these molars erupting, our dentist recommended and applied sealants to these teeth. However, because MetLife has a rigid policy concerning the child's age for this benefit, these sealants were not "covered".
Our dentist wrote a letter to MetLife explaining the atypical situation and reporting the existence of x-rays proving the teeth had not erupted until the 16th year. MetLife was unconcerned. They had a policy in place and even though the dentist prescribed this treatment and it was a "covered" treatment, they denied coverage because of the age exclusion. In my mind, this is clearly a loophole that they are using to increase their profits. My child could not have received these sealants "under age 14", because the teeth were not exposed at that age.
Because MetLife has this policy to hide behind, I am now forced to incur the full cost of these treatments. I am fine with paying for these treatments, but the issue is that I already pay dearly every month for my Dental PPO plan. So in effect, I am paying twice. MetLife gets to pocket the money I pay to them without providing any benefit because they have a rigid policy to hide behind. I then have to pay the dentist directly as well for a reasonable and customary treatment that is covered as part of the Dental PPO policy that I have purchased. It is no wonder the government wants to step in and do something to fix this profit-grubbing industry.