State of Denial: The Current Impact of Insurance Companies on Healthcare

Traci Hurley says watching her husband battle cancer in late 2021 was heartbreaking. “It was heartbreaking and horrible,” she said. “I lived in fear every day.”

An even worse battle, she said, because many of the skirmishes involved their insurance company. “No family should have to fight to get the treatment their doctor recommends, while fighting for their lives,” she said.

Millions of Americans report struggling to get medical care: either unable to pay sky-high deductibles or, like Dan Hurley, denied coverage for tests and treatments by health insurance companies. Not only were both Hurleys doctors; Dan, an ear, nose and throat surgeon, was also adept at cutting through insurance red tape for his patients.

“And yet we still encountered many problems,” Traci said. “If we as doctors had to fight as much as we had to fight to get approval for care, what about the people who don’t have medical knowledge? What happens to them every day?”

Dan was an avid hiker, until persistent back pain turned out to be cancer. He was diagnosed with chondrosarcoma, an ultra-rare bone tumor. In an attempt to save his life, the tumor, along with Dan’s hip, had to be removed. Insurance only covered part of the costs.

Traci said: “A lot of his treatments were refused. We’ve had PET scans, CT scans turned down. We’ve had chemotherapy, we’ve had radiation, we’ve had certain medications that required prior authorization and were denied.

According to Traci, the insurers’ refusals were based on the fact that they were “not medically indicated.”

“Make their lives as difficult as possible”

Ron Howrigon, now a consultant, spent two decades working for health insurance companies. “Health insurance companies know that five percent of their members bear 50 percent of all costs,” he said. “So I have this huge financial incentive to make their lives as difficult as possible.”

Howrigon says the business model is different from other industries: “The more your customers use your product, the less money you make. Your incentive is to prevent them from using your product.

How often do insurance companies refuse to cover the cost of medical treatment? It’s hard to say; Health insurance companies are only required to report denial data for plans purchased through Healthcare.gov.

A CBS News analysis of about 1.3 billion federal health insurance claims over three years shows that in 2024, insurers have denied 19% of in-network claims, or about 1 in 5.

But for the largest insurer, United Healthcare, that represents a sharp decline from the previous two years, when it denied up to a third of its federal claims.

Although it did not provide supporting data, United Healthcare claims that for all of its plans, their initial denial rate is 10%. They also point out that when employers are self-insured, the plans they choose for their employees dictate coverage decisions.

“Approximately 165 million Americans are enrolled in employer-sponsored health plans, and 65 percent of them are enrolled in what is called a self-insured plan,” United said in its release. “The health insurance company they choose provides administrative services such as processing member calls and paying claims. But as the phrase “self-insured” suggests, it is the employer’s funds that cover the payment of claims. …

“Self-insured employers can design their health plans and determine what will and will not be covered for their employees,” United continued. “It’s important to remember that your health insurer probably isn’t the one that designed it that way. Your employer did.”

“Insurance is out of control”

Dr. Elisabeth Potter, a surgeon who sees up to 60 breast cancer patients each week at her RedBud Surgery Center in Austin, Texas, said, “Honestly, insurance companies have made it harder to be healthy in the United States.

She says insurance denials actually increase costs: “I have two employees who spend almost all day navigating insurance. It seems like everywhere we turn there’s a problem, whether it’s an insurance company saying, “You know, we won’t cover your surgery at this surgery center” or “We won’t pay for this medication, we want you to take a different medication.” »

Case in point: Early one morning last fall, Jeannie Lee, a 40-year-old mother with breast cancer, was preparing for a procedure — lymphovenous bypass — that could have been performed two weeks earlier during her double mastectomy, but she and her husband’s insurance companies refused to cover the cost.

Lee is at high risk of developing a condition known as lymphedema. According to Potter, “it becomes very difficult to just use your arm. It can be painful. It gets swollen. It also becomes deformed.”

Lee said: “I’m 40 years old. I have three young children. It’s very necessary to have this procedure done.”

Once Lee was able to obtain financial assistance through a new nonprofit organization created by Dr. Potter, she resumed surgery. “This patient is having an additional operation, a separate general anesthesia, because her insurance company would not cover the operation,” Potter said. “We could have done this very easily at the same time (as his mastectomy).”

When she’s not in surgery, Potter is often on the phone defending her treatment decisions to insurance company medical directors who, she says, often know little about her field of medicine. “Sometimes, you know, I go to an eye doctor, an eye doctor. It was completely absurd,” she said.

She sometimes posts her version of these conversations online.

Potter: “So we’re talking about arm lymphedema. So, this is not an area that you are familiar with, is it?

But a video she posted in early January 2025, she says, ended up putting her entire medical practice at risk. While she was in the operating room, Potter said she received a call from United Healthcare. This “urgent” call, she said, was to question why her patient needed to spend the night in the hospital.

“This had never happened before. I didn’t know what was going on, but they said it was urgent and I needed to call, and that’s what I did,” she said. “I’m operating. I’m doing the right thing for the patient. I’m going to keep her overnight. I walked out of the hospital and I filmed myself in my unfiltered moment, you know.”

Potter: “It’s out of control. The insurance is out of control.”

Shortly after posting this video, she received a letter from the insurance company threatening to sue her for defamation. “I take great care of the patients. They just try to scare me into silence,” Potter told us.

I asked: “And you weren’t afraid?”

“I was afraid,” she replied.

United Healthcare did not sue Dr. Potter. They declined an on-camera interview, but a company spokesperson said the call was due to an erroneous order and that a doctor would never be asked to leave the office for a call regarding an insurance question.

“It was such a gut punch.”

Miranda Yaver, an assistant professor at the University of Pittsburgh, says insurance companies know that only a small percentage of people will appeal claim denials.

“We are all vulnerable to rejection,” she said. “We can’t all weather the storms easily when it comes to appealing and overcoming these barriers.”

Yaver calls this “rationing by inconvenience.”

“A lot of people don’t even know they can appeal,” Yaver said.

I asked, “Are you saying it’s not really denial that ends up stopping people from seeking treatment, it’s that people give up?” »

“Less than 1 percent of these network claim denials result in an appeal, even though people won about half the time,” Yaver said.

Obviously, it pays to appeal, but some patients, like Dr. Dan Hurley, who is battling an aggressive cancer, are short on time. Much of his final months were spent, says his wife Traci, on the phone with insurance company personnel: “He would meet with them line by line and they would say, ‘Okay, yes, we need to get a supervisor involved. We’ll call you back.’ And then they don’t. »

Dan’s goal, she said, was to see insurance companies held to similar standards as doctors, making them liable for malpractice when they deny life-saving care. “Signing this disclaimer is practicing medicine,” Traci said, “in the same way, if a patient comes to see me and I make a decision about treatment and that decision goes wrong, I’m responsible. That’s how it works.”

Dan Hurley died on August 3, 2023. A week later, his wife received a letter from the insurance company asking her to pay $80,000 for a round of chemotherapy that had been pre-authorized, but was suddenly denied retroactively. “It was a real gut punch to get it that day,” she said. “It’s incredible, isn’t it? Almost laughable.”

Dan Hurley’s fight became his widow’s. “There’s a part of me that’s like, ‘Oh, he’d be so proud of me,’ but there’s also a part of me that’s like, ‘Come on, chop, chop, you’ve got this, let’s go, pick it up, don’t be sad, you know, keep going.’ Because that’s how he was.”

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Story produced by Sari Aviv. Editor: Jason Schmidt.