I'm not familiar with the structure of and players in the US healthcare insurance market, being a Brit and all that, but it seems to me that denying 90% of claims isn't a sustainable business model in the long run, at least in theory, because a significant proportion of customers will calculate that paying the premiums isn't worth the risk and will either choose to place their business with a competitor (if possible) or simply self-insure (ie, do without).
Where to start?
Ahem, a ton of people purchase their insurance through their employer; however, what they pay in terms of premium and deductible is substantially reduced due to bargaining agreements between employers and insurance companies. Additionally, because insurance is so expensive, employers usually offer packages where they pay part of the premium, making it affordable for the employee. Simply put, many of us have virtually no choice as to where we obtain insurance, becase anything outside of what the employer offers is astronomical, price-wise.
Not having insurance is generally
not an option, although many young people take the risk and do it. The reason that it's not an option for many is that one serious illness, one car accident, etc., can make you lose everything. Your house, your car, your savings. Everything. (That's why it's generally young people who do this. They have little to lose.)
Denying 90% of claims seems high, but the reality of it is, whether it's denial of 50% of claims or 90%, or anything in between; or whether it's simply making patients jump through hoops to get the insurance company to payout,; or whether it's people or AI making the decisions; this has been going on for many, many years, and insurance companies just keep getting bigger, and their CEO's, and CFO's, and CTO's, and all the other fat-cats at the top are raking in millions between stock options, bonuses, and annual salaries (which are generally a tiny part of the compensation packages).
I won't bore you with all of my insurance woes, but maybe a little example is in order: As a contract employee, the best deal I've been able to get on insurance is this (I'm talking about one person, 50 - 60 years old and in decent health):
My premiums are right around $900/ month, and I have a deductible of almost $5,000 per year. In addition, I pay a $35 co-pay at each visit, which I continue to pay after the deductible is met. Between premiums and deductible, that's $15,000 per year, should I have enough medical bills to hit the deductible. So, with no
medical bills at all, I'll pay over $10,000 per year. If I need medical care, I'll pay that, plus the $35 co-pay per visit, if it's significant care, $5,000 more out of pocket. When I reach the deductible, I'll still be fighting every claim, begging doctors to write letters stating and re-stating and re-formulating my need for a certain drug or treatment, because it's listed on an "as-needed" basis, and the original claim the doctor sent in didn't fulfill that need, per the insurance company. Yada, yada, yada. On and on it goes.
That is the state of insurance in the U.S. for many of us.
Sorry for the long post folks, but there is much "insurance pain" out there!