Many US domestic health insurers are taking responsibility for covering the cost of addiction treatment within the US, because it appears that they recognize the adverse effects of substance abuse and the results of specific behavioural addictions which can have either psychiatric consequence or impact upon ongoing physical effects that require costly maintenance throughout a policyholder’s lifetime.
After investigation with a selected group of domestic and expatriate risk insurers in Canada, the UK and the US, it appears that most major insurers of health in North America and globally are facing up in differing ways to this need for mental healthcare benefit. Indeed, many insurers in Canada and the US are fielding up to 12 specific enquiries per month per region (province, territory or state) from their policyholders, openly seeking Recovery from Addiction based provider facility referrals. While historically the practice has been to meet these types of request with the standard industry gambit, which is usually a NOT COVERED response of definitive exclusion as so illustrated;
The following treatment items, conditions, activities and their related or consequential expenses are excluded from the policy and the company will not be liable for them:
Treatment of self-inflicted injury, suicide, abuse of alcohol, drug addiction or abuse and sexually transmitted diseases.
With the exception of a selected few US domestic underwriters who extend services to include this class of benefit, there is evidence emerging that recent practice is somewhat contrary to the traditional approach; healthcare delivery requests and referrals within this niche sector provide clear proof of staple AAA rated global insurance underwriters looking beyond traditional barriers and openly making referrals for clients— irrespective of whether or not their insurance policy actually extends to cover this benefit. Many who do not extend insurance benefit, (for example certain underwriters at Lloyds among other notable European & Canadian insurers) to pay for these services see the provision of qualified information as a duty of care to their policyholders and are now openly seeking out credentialed and industry accredited Recovery Center providers across the continent, to become a part of their healthcare preferred provider networks.
While standard global industry practice has typically been to SPECIFICALLY EXCLUDE addiction, recovery and related services from sectional insurance policy benefit limits, there is emerging an apparent change in attitude and departure from the status quo. Actuaries and insurance underwriters are becoming more accepting, understanding and accommodating of emerging industry practices and responding to needs of policyholders in managing healthcare in a more holistic fashion.
They are also bowing to pressure exerted by patient advocacy groups globally and abuse and sexually transmitted diseases.
They are also bowing to pressure exerted by patient advocacy groups globally and are considering the position of many former ‘fringe or alternative medicine’ based areas of benefit provision and in reflection are extending new benefit allowances, (though capitated) to manage and measure carefully this area of risk exposure, frequency and rates of claims fund utilization. There is recent evidence that some EU and North American insurers are extending benefit to include recovery based treatment episodes in specific global locations. CIGNA, MSH and Blue Cross Blue Shield have certain policies that extend this benefit provision as a standard within their policy terms and conditions and the hope within the Recovery sector internationally is that this trend, which is hugely positive, is set to continue.
A note of caution: while this new benefits tolerance is becoming more evident, it will be subject to measurement using standard, usual and customary fee criterion along with empirical data and insurance risk controls associated with the management of healthcare costs and risk. In the land of insurance underwriting based residential recovery service provision, the impact and availability of this extended sectional limit upon the overall claims fund will continue to be closely monitored and the loss ratios will ultimately, be king!