What can you do about an insurance company if you feel or suspect that there is a problem? Remember, your doctor has very little power compared with the insurance company because of a long and deliberately vague contract that he/she is required to sign. You, the patient, have some power because of two or three things: pull with your own company, possible media (TV, radio) exposure and complaints to the state insurance commissioner. Your complaint to the state insurance commissioner is usually the most helpful item, unless the commissioner is on the "payroll" of your particular insurance company. (Yes, this can happen.) Insurance companies, and especially their employees, do not like paperwork and answering questions when they know their answers may incriminate them, especially if it means working during break or lunch hour or after 3:00 PM! Frequently, sending your state insurance commissioner a copy of your complaint letter by certified mail will get a positive response. If this fails, you may consider hiring a lawyer to reach the state insurance commissioner. The media can be the next approach, if you have connections or if you have an interesting case.

It would be provocative to take a survey of where politicians and insurance-company officials have most of their medical treatment. Congress and the President get theirs from the best doctors at Bathesda Naval Hospital. I would wager that they have not themselves signed up for HMO's. It is amazing that both Congress and the President's Clinton and George W. Bush were working hard to force most senior citizens from the traditional Medicare, plus a secondary, into (mis)managed care. In Florida, if an HMO or managed-care company causes the death of (kills) an elderly person, the state does not allow a lawsuit against the company unless the suit is filed by a surviving spouse or dependent child. Managed-care companies really like Florida for this reason: unlimited profits with little liability.

My final point about insurance companies is for patients on Medicare as their primary carrier, many of whom have told me that the cost of their secondary insurance has risen greatly over the last year or two, sometimes doubling. Keep in mind that the insurance company, no matter which one it is, is usually responsible only for the 20% of the "reasonable and necessary" portion of the doctor's or hospital's bill that Medicare does not pay. If Medicare, on a per-patient basis, is now paying less than 2/3 of what it paid in 1994 for many procedures, then the cost to the insurance company should also have dropped by at least 1/3 since 1994. Remember that the secondary insurance company's payment cannot be greater than the 20% that Medicare does not cover! Secondary policies rarely cover anything else.

This is just another win-win for the insurance companies. (So what's new?) Gouge seniors now for more money for traditional secondary coverage, thus forcing them into the HMO's in 1999, so that the seniors can "save money." Little do seniors know that the U.S. Government will pay every HMO about $2,500 in advance in 1999 for every senior who has signed up. The moment a senior costs over $2,500 in hospital or doctor bills, the insurance company will lose money, or decrease net profit, or decrease the stock value or the insurance company's stock-market capitalization, providing a strong motivation to deny or delay necessary care. Offer some kind of apparently attractive "drug benefit" that really is restrictive and usually highly generic-based or does not even allow some of the prescribed medicines at all and you can lure a lot of unsuspecting seniors.

How many seniors will die needlessly, or prematurely? The government itself may have incentive to steer seniors to this HMO plan. The longer a senior citizen lives, the more he/she costs Social Security. To politicians, HMO's may have, as an indirect "benefit," population control.

One can readily understand the purpose of HMO's and health insurance companies in The Wall Street Journal and Investors Business Daily, where the bottom line (money) counts. In managed care it is simply the bottom line that controls health care coverage, so, caveat emptor, or "let the buyer beware" when dealing with your "good neighbor" who may have "good hands." If you are lucky and healthy, then "managed care" may be a worthwhile gamble.

Is there another way to fight managed care? What if a patient is injured because of a managed care, HMO or PPO rule, act or decision? How can John Q. Public recover against all these insurance company defenses? We think the following arguments may need to be tested in court.

In the past, there have been occasions when an unscrupulous insurance salesperson has intentionally misled a consumer for the purpose of selling insurance in order to gain the portion of the premium(s), that accrues to the salesperson (commission), with the design that the consumer not receive the benefits (s)he thought were purchased. Even with the advent of "plain English" contract requirements in some states, insurance contracts are inherently so complex, with clauses depending on definitions in other clauses, ad infinitum, that only other insurance people, or lawyers and accountants who specialize in insurance, are able to make complete sense of them. Thus, although the salesperson is legally and literally the agent of the insurance company (the carrier), the consumer is frequently completely dependent upon that salesperson for an explanation of the contract, prior to signing it.

Such dishonesty is called "fraud in the inducement," meaning that, but for the fraudulent explanation by the salesperson, the consumer would not have bought the product or paid that price for it, i.e., the fraud induced the consumer to purchase the insurance at that price. The consumer has parted with something of value (in this case, the premium payments) in reliance upon the salesperson's intentional perversion of the truth, to the benefit of the salesperson (and the carrier). Fraud may be any kind of artifice (trick, concealment, etc.) employed by one person to deceive another, whether by words or conduct, whether they constitute positive allegations or concealment of that which should have been disclosed (stated outright). "Bad faith" and "fraud" are synonymous in meaning, although bad faith usually comes after the fact, while fraud, as noted above, can occur even before the contract is signed.

In some states, fraud in the inducement will cause a court to nullify and void the contract, should that be the desire of the person defrauded. That may not be helpful, if the consumer has already suffered damages in reliance upon the fraudulent misrepresentations of the insurance salesperson, because one cannot sue for damages upon the basis of a null and void contract. In some states, if the fraud has caused injury, whether physical, mental or financial, to the person defrauded, that person is entitled to be awarded damages, even to the extent of triple damages in some situations. Sometimes, the attorney's fees of the person defrauded are also awarded against the defrauding party. Lest you say to yourself, in response to the latter, that your insurance agent has nothing against which to execute any judgment that might be awarded in your favor (i.e., collect), be aware that, generally speaking, the master (insurance carrier) is responsible for the actions and representations (words) of his/her/its agent (insurance salesperson). Under appropriate circumstances, the carrier is sued along with the agent, anyway.

It may be possible to use the "fraud" or "bad faith" argument against a managed-care company. Such a lawsuit might lie in equity (be based on equitable considerations, i.e., fairness) rather than the statue protecting managed-care companies from lawsuit. Judgment in such a case might, for example, require the managed-care company to arrange to provide the injured or ill consumer appropriate medical care, rather than money damages. Courts are, however, loathe to become involved in day-to-day oversight of performance of such judgment, civil rights busing cases to the contrary notwithstanding.

It may be possible to use this argument against managed care. What if a patient asked the agent "Will I get excellent care that meets all my needs?" What if the agent says "yes" or better yet, puts the answer in writing?

However, even in light of the law's efforts to make an injured party "whole," it is always better to avoid the problem at the very beginning. Sometimes, such as in the case where an insured person is irreparably injured or dies as a result of the actions of an insurance company in the performance of the contract, no amount of money can compensate adequately for the loss.

Read what you intend to sign. REMEMBER that what you sign may not be the actual policy. Before you commit to anything, even in your own mind, REQUIRE the agent to provide you with a copy of the actual policy. Spend time going over it. It will probably be very complex. If you don't understand it, find someone who has your interests at hear to explain it to you. This might be an agent (of another carrier) who is your longtime friend, upon whom you can rely with confidence, or an attorney or accountant who specializes in insurance law, preferably health insurance. Such attorneys are usually listed in the yellow Pages, under Attorneys-Health Law or Attorneys ­ Insurance Law.

What you are looking for is not in the policy. What you are looking for is what is not covered, over and above the exclusions actually set forth in the policy. It may be difficult for you to imagine every instance in which you might need coverage that is not addressed in the policy. This is why you need someone who is expert in the field of health insurance to review the actual policy with you before you sign the contract.

Inadequate health insurance is the worst investment you can make. Lack of coverage for health catastrophes could leave you penniless. It is worth your time and money to investigate thoroughly the actual policies you are considering.