A story about Greed (well, maybe)
Fable-tastic!
The Insurance Lesson
Nora took great pride in her vocation as a Claims Examiner. Daily, she would approve or deny health benefits to her accounts with accuracy and poise. She could smell a false claim and inwardly despised anyone who would try to extort money from her firm. She also could not be happier to provide the means for legitimate customers to care for themselves and their families. If it were not for her, she often said, health care would be provided only for the unworthy and the common man making his way in the world would be lost.
But not every claim was simple. She often spent hours researching and consulting upon the occasional difficult claim that was sent her way. She would grill hospital staff, accounting firms, resident assistants, and lawyers for hours if it were needed. In the end, most claims hinged on only one fact or another and it was her job to discover what that was.
One such case was that of Tyrone Smith. Mr. Smith had called Nora to inquire about mental health benefits. The conversation became heated when Nora inquired as to his diagnosis.
“What diagnosis?” Mr. Smith screamed into the receiver, “I’m coming apart here and you want me to give you a diagnosis?”
Nora calmly said, “Yes, Mr. Smith, that is how we determine treatment, whatever the ailment. I recommend that you check our website for a care provider in our net-“
“I did,” Mr. Smith ranted, “I called 16 doctors and none of them can see me before next week!”
“If you are experiencing a medical emergency, I suggest that you visit your nearest emergency room, Mr. Smith.”
“It’s,” Mr. Smith sputtered, “It’s not the kind of emergency! I don’t need a trauma doctor, I need someone who can administer a god-damn antipsychotic!”
“There is not reason to use that language Mr. Smith,” Nora said evenly. “I am trying to help you.”
“Help me? You haven’t helped me yet! Get with the helping me! Tell me someplace I can go!”
Nora thumbed through her directory, “Did you say you lived in Springfield, sir?”
“Yes, yes, Springfield.”
“Alright, Saint Joan’s hospital is near you and it has a mental care ward, I suggest you go there.”
“Oh, alright.”
“But Mr. Smith, I must caution you that your treatment may not be covered by your insurance, you have to tell the doctors that they need to call us here, ok?”
But it was too late, for Mr. Smith had already hung up. Well, Nora thought to herself, at least he will find someone who can help him there.
The Saint Joan’s mental ward gave her a call a few hours later to inquire if Mr. Smith was a customer of Nora’s firm.
“Yes, he is with us,” Nora announced proudly.
“Well, he’s in quite a state here. But he mentioned he’d like approval for inpatient care,” the nurse informed her.
“A hospital stay of up to 5 days is permissible without a referral. He will need to contact his primary care physician at the soonest possible convenience if he wishes to stay longer and a formal diagnosis will be required.”
“Thank you for the information,” the nurse said and hung up.
Mr. Creed knocked on Nora’s door.
“Yes sir, come in,” Nora said with fatigue.
“I got those medical records you ordered,” Creed said mildly.
“Excellent, and the news?”
“Mr. Smith has been in and out of mental care for years. He had a preexisting condition.”
Nora clicked her tongue in irritation. “It’s unfortunate that he didn’t mention that on his application. We simply can’t pay for someone who lies to us about his conditions.”
For several days, Nora did not hear from Mr. Smith or Saint Joan’s hospital. When she received the bill for inpatient care, she denied it as a matter of course and sent the appropriate letters with Mr. Smith’s application information.
Due to her heavy workload, she did not give this a second thought. Not any thought, in fact, until Mr. Creed appeared at her door once more with a frantic look.
“Aren’t you supposed to knock,” Nora said, not looking up from her paperwork.
“Of course, but as your manager it is my duty to give you things in a timely manner.”
Nora turned and looked at Mr. Creed from over the rims of her glasses. “Well?” she asked.
“We have a number of people with gunshot wounds.”
Nora turned back to her work, “We don’t cover gang incidents. Pass on my regards to the police.”
“This isn’t a gang shooting Nora,” Mr. Creed frowned. “You really should get out of the office sometimes and read a newspaper or watch the television. This was a sniper.”
“Oh,” Nora said tired, “Put it here.”
Mr. Creed stepped into her office at last and set the folios down next to her. “I want you to make this your top priority, ok?”
Nora sighed, “Alright Mr. Creed.”
She opened up the folios and spread them out on the desk. It seemed curious to her that all four were patients of their from Springfield. A disagreeable sensation formed in her gut as she viewed the medical records. Nora noted the facts: Three adults and one child had been shot down in Washington square by a sniper in the clock tower. They were not related in any way except that they were in the same place at the same time and happened to be customers of her firm. Their medical records were in order and each had a suitable history of regular care. The surgery requested to repair these people was almost a million dollars, not including hospital stay, transportation, physical therapy, and potential ongoing treatments.
She phoned the hospital and made the appropriate approvals. She could sort out the details later but for now, these people needed to be treated for trauma.
Once completed, she set down the telephone. She narrowed her eyes and stood up. She clicked down the hall from her office to the employee lounge.
She turned on the television using the power button on the box itself and manually flipped through the channels. It was all over the news syndicates.
But what disturbed Nora the most was the identity of the sniper, who was none other than Tyrone Smith, a local who had a history of mental illness. Reporters at the scene were interviewing witnesses, and most asked why this man had not been put away.
Nora turned the television off.
Mr. Creed cleared his throat behind her. “I know this isn’t easy to take.”
“Easy to take,” Nora said. “Sir, this is not easy to take, but what really doesn’t make sense is that this will cost us millions. And if we deny any service to these people, any personal injury lawyer will be chomping at the bit to take us to the cleaners.”
Nora paused. Mr. Creed winced a little.
Nora continued, “If we had simply taken care of Mr. Smith, whom I know you reviewed for me just last week, we wouldn’t have 4 customers with severe injuries that we are obligated to pay for.”
Mr. Creed held his hand out, palms up, “Try to understand Nora, it was an accident.”
Nora sighed and gazed at her feet for a moment. “It still doesn’t make sense. We could have taken a dangerous man off the street for nickels on the dollar compared to the damage he did out there. I am the first to admit that lying on an application is reasonable grounds, but shouldn’t there be a policy about dangerously unstable people?”
“Unfortunately no, Nora,” Mr. Creed said. “We can’t advocate people lying.”
“Well, what about the diagnosis of the doctors he was seeing?”
“We didn’t even get it, Nora. He was already denied.”
Nora paced a little.
Mr Creed let his hands drop, “Look, we did the best we could have under the circumstances and it was just really unlucky that four people on our plan were hit. The chances of four victims being customers of ours in a crowd of strangers when a sniper hits are slim to none.”
-FW
The Insurance Lesson
Nora took great pride in her vocation as a Claims Examiner. Daily, she would approve or deny health benefits to her accounts with accuracy and poise. She could smell a false claim and inwardly despised anyone who would try to extort money from her firm. She also could not be happier to provide the means for legitimate customers to care for themselves and their families. If it were not for her, she often said, health care would be provided only for the unworthy and the common man making his way in the world would be lost.
But not every claim was simple. She often spent hours researching and consulting upon the occasional difficult claim that was sent her way. She would grill hospital staff, accounting firms, resident assistants, and lawyers for hours if it were needed. In the end, most claims hinged on only one fact or another and it was her job to discover what that was.
One such case was that of Tyrone Smith. Mr. Smith had called Nora to inquire about mental health benefits. The conversation became heated when Nora inquired as to his diagnosis.
“What diagnosis?” Mr. Smith screamed into the receiver, “I’m coming apart here and you want me to give you a diagnosis?”
Nora calmly said, “Yes, Mr. Smith, that is how we determine treatment, whatever the ailment. I recommend that you check our website for a care provider in our net-“
“I did,” Mr. Smith ranted, “I called 16 doctors and none of them can see me before next week!”
“If you are experiencing a medical emergency, I suggest that you visit your nearest emergency room, Mr. Smith.”
“It’s,” Mr. Smith sputtered, “It’s not the kind of emergency! I don’t need a trauma doctor, I need someone who can administer a god-damn antipsychotic!”
“There is not reason to use that language Mr. Smith,” Nora said evenly. “I am trying to help you.”
“Help me? You haven’t helped me yet! Get with the helping me! Tell me someplace I can go!”
Nora thumbed through her directory, “Did you say you lived in Springfield, sir?”
“Yes, yes, Springfield.”
“Alright, Saint Joan’s hospital is near you and it has a mental care ward, I suggest you go there.”
“Oh, alright.”
“But Mr. Smith, I must caution you that your treatment may not be covered by your insurance, you have to tell the doctors that they need to call us here, ok?”
But it was too late, for Mr. Smith had already hung up. Well, Nora thought to herself, at least he will find someone who can help him there.
The Saint Joan’s mental ward gave her a call a few hours later to inquire if Mr. Smith was a customer of Nora’s firm.
“Yes, he is with us,” Nora announced proudly.
“Well, he’s in quite a state here. But he mentioned he’d like approval for inpatient care,” the nurse informed her.
“A hospital stay of up to 5 days is permissible without a referral. He will need to contact his primary care physician at the soonest possible convenience if he wishes to stay longer and a formal diagnosis will be required.”
“Thank you for the information,” the nurse said and hung up.
Mr. Creed knocked on Nora’s door.
“Yes sir, come in,” Nora said with fatigue.
“I got those medical records you ordered,” Creed said mildly.
“Excellent, and the news?”
“Mr. Smith has been in and out of mental care for years. He had a preexisting condition.”
Nora clicked her tongue in irritation. “It’s unfortunate that he didn’t mention that on his application. We simply can’t pay for someone who lies to us about his conditions.”
For several days, Nora did not hear from Mr. Smith or Saint Joan’s hospital. When she received the bill for inpatient care, she denied it as a matter of course and sent the appropriate letters with Mr. Smith’s application information.
Due to her heavy workload, she did not give this a second thought. Not any thought, in fact, until Mr. Creed appeared at her door once more with a frantic look.
“Aren’t you supposed to knock,” Nora said, not looking up from her paperwork.
“Of course, but as your manager it is my duty to give you things in a timely manner.”
Nora turned and looked at Mr. Creed from over the rims of her glasses. “Well?” she asked.
“We have a number of people with gunshot wounds.”
Nora turned back to her work, “We don’t cover gang incidents. Pass on my regards to the police.”
“This isn’t a gang shooting Nora,” Mr. Creed frowned. “You really should get out of the office sometimes and read a newspaper or watch the television. This was a sniper.”
“Oh,” Nora said tired, “Put it here.”
Mr. Creed stepped into her office at last and set the folios down next to her. “I want you to make this your top priority, ok?”
Nora sighed, “Alright Mr. Creed.”
She opened up the folios and spread them out on the desk. It seemed curious to her that all four were patients of their from Springfield. A disagreeable sensation formed in her gut as she viewed the medical records. Nora noted the facts: Three adults and one child had been shot down in Washington square by a sniper in the clock tower. They were not related in any way except that they were in the same place at the same time and happened to be customers of her firm. Their medical records were in order and each had a suitable history of regular care. The surgery requested to repair these people was almost a million dollars, not including hospital stay, transportation, physical therapy, and potential ongoing treatments.
She phoned the hospital and made the appropriate approvals. She could sort out the details later but for now, these people needed to be treated for trauma.
Once completed, she set down the telephone. She narrowed her eyes and stood up. She clicked down the hall from her office to the employee lounge.
She turned on the television using the power button on the box itself and manually flipped through the channels. It was all over the news syndicates.
But what disturbed Nora the most was the identity of the sniper, who was none other than Tyrone Smith, a local who had a history of mental illness. Reporters at the scene were interviewing witnesses, and most asked why this man had not been put away.
Nora turned the television off.
Mr. Creed cleared his throat behind her. “I know this isn’t easy to take.”
“Easy to take,” Nora said. “Sir, this is not easy to take, but what really doesn’t make sense is that this will cost us millions. And if we deny any service to these people, any personal injury lawyer will be chomping at the bit to take us to the cleaners.”
Nora paused. Mr. Creed winced a little.
Nora continued, “If we had simply taken care of Mr. Smith, whom I know you reviewed for me just last week, we wouldn’t have 4 customers with severe injuries that we are obligated to pay for.”
Mr. Creed held his hand out, palms up, “Try to understand Nora, it was an accident.”
Nora sighed and gazed at her feet for a moment. “It still doesn’t make sense. We could have taken a dangerous man off the street for nickels on the dollar compared to the damage he did out there. I am the first to admit that lying on an application is reasonable grounds, but shouldn’t there be a policy about dangerously unstable people?”
“Unfortunately no, Nora,” Mr. Creed said. “We can’t advocate people lying.”
“Well, what about the diagnosis of the doctors he was seeing?”
“We didn’t even get it, Nora. He was already denied.”
Nora paced a little.
Mr Creed let his hands drop, “Look, we did the best we could have under the circumstances and it was just really unlucky that four people on our plan were hit. The chances of four victims being customers of ours in a crowd of strangers when a sniper hits are slim to none.”
-FW