Case Study on "Ethical and Legal Perspectives in Health Care"

Case Study 6 pages (1893 words) Sources: 4

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Ethical and Legal Perspectives in Health Care

For one to become an effective manager, it is crucial to understand the basic ethical and legal principles influencing the work setting. This includes the legal relationship between the consumer and the health insurance company. Ethical behaviors are viewed as right actions in a society. It may not be what the law requires because the health insurance industry is flawed with challenging situations, which involve ethical dilemmas (Sandel, 2007). This study focuses on the ethical and legal responsibilities of the health insurance company regarding the consumer.

An insurance company can require insurance recipients to pay a different premium for the same coverage

Assuming that a recipient has a higher income, the law requires an adjustment to his/her monthly premium and Medicare prescribed medication premiums. Beneficiaries with higher incomes pay higher premiums. These influences less than 5% of individuals with Medicare, so most individuals do not pay a higher premium. Assuming that a recipient is a high-income beneficiary with Medicare coverage, he/she will pay monthly premiums, in addition to an extra amount (Cassens, 2012). Because individual plan premiums fluctuate, the law details that the amount is established based on one base premium. Insurance companies tie the extra cost the recipient pays to the base beneficiary premium, not the individual premium amount.

Assuming that the recipient is a higher-income beneficiary, the company deducts this amount from the monthly Social Security installments paying little heed to how he/she normally pays the monthly amount premiums. Assuming t

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hat the amount is greater than the monthly premium, the recipient will get a separate bill from an alternate government agency such as the Centers for Medicare & Medicaid Services. To establish whether a recipient will pay higher premiums, Social Security utilizes the latest Federal government form that the IRS gives to insurance companies (Ebersole, 2008). If an individual is required to pay higher premiums, the company utilizes a sliding scale to make the modification. They base the sliding scale on the recipient's adjusted gross income. A recipient's MAGI are the aggregate of his/her tax exempt interest income and adjusted gross income.

The insurance company requires the insurance recipient to undergo required tests

The insurance agency requires the disclosure of previous medical conditions and a family medical history when individuals request for inability, medicinal or life insurance. In a few cases, the applicant must undergo a medical examination. From this data, the insurance agency chooses whether to offer coverage assuming that this is the case at any cost. Genetic breakthrough now permits persons to be tested for uncommon medical conditions such as cystic fibrosis and Huntington's infection. Additionally, hereditary testing can uncover an expanded danger of additional regular conditions, incorporating prostrate, lymphoma and leukemia. Concerns have been raised that once these tests get competitive, insurance agencies will utilize the findings to limit or deny coverage (Dziegielewski, 2009).

Research findings published in the early 1990s demonstrate that persons are being denied insurance coverage because of the danger of hereditary illness. The prospect of widespread genetic discrimination inconveniences numerous experts in the legal and medical communities. It is unreasonable for them to charge, deny the person coverage, or charge higher premiums because of a potential danger of hereditary illness that the individual is powerless in changing (Cassens, 2012). The health insurance business, which presently collects medical data on hereditary infection through the assessment of therapeutic records and family histories, reacts that an integral standard in writing insurance is charging individuals rates that reflect their health risks. This implies that every applicant pays the fairest conceivable cost, in view of her distinctive attributes. The industry additionally notes that worries about hereditary testing do not become the most significant factor with group health plans, where rates are dependent upon methods other than distinctive assessments (Holland & June 2010).

An insurance agency has the right to make a recipient submit to a medical exam when he/she requests an individual life coverage policy. In addition, applicants must not be amazed if the organizations that an applicant applies to practice this right, particularly assuming that the applicant might be more senior or have a history of health issues. A client's present health is one of the key variables that organizations use to assess him/her as an insurance risk. If an organization requests that an applicant undergo a medical exam and the applicant declines, the organization might decline to offer a life insurance policy (Ebersole, 2008).

Assuming that applicants consent to taking the medicinal exam, they should anticipate that it would be equitably broad. In any event, the exam will include addressing medical inquiries, being weighed, and urine and blood tests. Physical exams such as stress tests and different tests might additionally be needed assuming that an applicant is requesting a large amount of life coverage. An autonomous specialist or nurse who accepts installment from the insurance agency performs the medical exam (Cassens, 2012). The organization will utilize the results of this exam and other data to figure out if an applicant is insurable. In any case, the amount he/she may as well pay for the coverage. Without a medicinal exam, the amount of coverage an applicant can buy could be limited. Usually, applicants will not need to take a medical exam or respond to medical inquiries to register in an employer sponsored coverage or group plan. This implies that applicants will not be charged progressively for coverage in the event that they are in poor health. The underlying reason is that insurance agencies base premiums for group plans on the risk elements of the overall group, not on individual elements about applicants. Above certain points of confinement, applicants will be asked medical questions, and the insurance agency can decline to offer an additional group insurance cover (Holland & June 2010).

The insurance company is discriminating against the insurance recipients who have heredity or predisposing health risk factors

Insurance agencies can legally discriminate against insurance recipients in certain circumstances. However, when an applicant feels that an insurance company has unfairly discriminated against him/her, the actions of the insurer might be lawful. The state and federal legislation affirms the business nature of annuity and life insurance as a form of voluntary mutually rated protection. In this case, the health insurance company's tendency includes differentiating between applicants based on their health status and family histories of health issues. Under section 46 of the Disability Discrimination Act 1992 and segment 44 of the Equal Opportunity Act 1995, an insurance agency offering life or annuity protection can legitimately discriminate on the ground of anticipated health dangers if the discrimination is based upon actuarial or factual information and discrimination is sensible (Ebersole, 2008).

The insurance items secured by this provision incorporate insurance for disability, life, trauma, bank loans and business. Insurance companies have the opportunity to prove this if an applicant lodges a formal complaint. Health insurance firms collect medical data on heredity or predisposing health factors through the assessment of medical records and family histories. It is shown that the integral standard writing insurance is based on charging individuals rates that reflect their health risks. This implies that every applicant pays the fairest conceivable cost, in view of his/her distinctive health risks (Ebersole, 2008).

The health insurance company is legally and ethically, required to offer assistance for insurance recipients who need to lower their rating

Health insurance managers advance an individual code of ethics within the company. When developing the code of ethics, they are influenced by numerous perspectives in life. Healthcare covers numerous diverse people and calls for assisting them simultaneously. Managers need to take care of numerous moral issues. Both experiences and nascent health insurance managers use various sources to improve and refine their individual ethic. Prime among them is a professional code of ethics. This incorporates educational socialization, organization culture and values, the superiors and subordinates (Cassens, 2012).

Code of ethics within the health insurance industry provides managers with appropriate behavior patterns. The ethical code for managers outlines guidelines for developing proper relationships with patients. This code of ethics guides the manager to build trust between the health insurance company and the applicant. This involves complying with legal regulations. The code of ethics must be strictly adhered when providing health coverage to applicants (Sandel, 2007). This ensures the highest level of patient satisfaction depending on the health issue. As a manager, I may also give whatever is vital to furnish appropriate care for the patient. The organization ought to be kept in accordance to the principles and the law. A personal ethical code that I feel could profit a health insurance company might incorporate honesty and uprightness.

Fairness

Fairness and justice are part of nurturing the well-being of all applicants. It involves acting in ways that consider the rights and needs of others and one's needs or wishes. It means sharing burdens in a manner that does not misuse or place an unreasonable burden on a customer for the benefit of the insurance company. For instance, insurance agencies reducing doctors'… READ MORE

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Quoted Instructions for "Ethical and Legal Perspectives in Health Care" Assignment:

“

You are employed in an administrative position at a large health insurance company. The board of directors of the company will be instituting a *****get health/stay health***** clause in their health insurance policies. This clause would state that all insurance recipients must complete a health review which will include a complete physical, blood pressure check, cholesterol check, blood glucose check and BMI. The insurance recipient will be rated utilizing a point system on the above criteria. Any health insurance recipient who scores above a certain number (which is an indicator of an increased possibility of health problems) will be required to pay a higher premium (the higher the number, the higher the premium). This higher insurance premium will continue until the health insurance recipient reduces their blood pressure, cholesterol, BMI, etc. and receives a lower rating.

Answer the following questions:

1) Can an insurance company require insurance recipients to pay a different premium for the same coverage? Is this legal? If yes, what law or statues takes precedence? If no, which law or statue takes precedence? (Answer EACH aspect of the question including legality issues. Defends legality conclusion. Incorporated pertinent laws.)

2) Can the insurance company require the insurance recipient to undergo required tests? What if the insurance recipient refuses to comply with the testing requirement? (Answer EACH aspect of the question including medical testing and compliance. Incorporated pertinent laws.)

3) Is the insurance company discriminating again the insurance recipients who have heredity or predisposing health risk factors. Why or why not? If so, is this practice ethical? (Answer EACH aspect of the question including discrimination and predisposing risk factors. Incorporated pertinent laws.)

4) Is the health insurance company legally and/or ethically required to offer assistance for insurance recipients who need to lower their rating? Support your opinion. (Answer EACH aspect of the question. Explains ethical and legal ramifications of requiring insurance recipient testing. Incorporated pertinent laws.)

Note:

a) Include an introduction and conclusion.

b) Re-state each question prior to answering.

c) In answering these questions, include any pertinent laws. APA format is required.

d) You must have a minimum of 4 online references with appropriate in-text citations (Use only online (!) sources and free (!) accessible web sites. Do not use any payable libraries or websites, where you need to log in to view the articles, because I need to read and review the material. Please include the title of the article, author and link in the references).

Thank you.

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