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Notes -
I don't have enough insight into their inner workings to be able to answer this. But my guess is they are targeting some positive profit margin (since they would have to) and creating actuarial rules to target this number. Then claims etc are mostly following an algorithm. But then again given as I have alleged the "non-insurable" nature of health, they are probably having to constantly tweak this.
I doubt they're frequently making individual case-by-case decisions to deny somebody for the sake of let's-get-rich-and-do-coke, but maybe I inappropriately assume people aren't monsters.
In any case I'd want to see evidence of such backroom decisions because it's quite an allegation. But that would be hard because I'd also want to see that it's not just "this guy is trying to spend infinite money to eke out another month and unfortunately we don't have that" sort of thing. Like my point is it's actually really hard to prove actual malice here.
I think directionally, yes. It’s just good resource allocation to look at the actuarial data and say “this drug might marginally improve your life for a few months, but you’re old or in bad shape physically and thus your treatment makes no sense.”
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