pjbooks Chapter 193 Jimmy and the Mother of Dragons
Chapter 193 Jimmy and the Mother of Dragons
Chapter 193 Jimmy and the Mother of Dragons
The term "refusal to pay out" is easy to understand literally: it means refusing to pay out insurance money.
As private enterprises, insurance companies that sell medical insurance typically have extremely strict health review mechanisms.
The rejection rate of the examiners directly affects their income level. After all, the more rejections, the more money the company saves. Which boss doesn't like such an employee?
This means that examiners can fabricate reasons to refuse compensation, or even without any reason at all.
A class-action lawsuit reveals that three doctors employed by insurance giant Cigna denied more than 300,000 claims within two months.
If we only consider working hours, on average, about 5 patients are denied insurance every minute, a level that even quantum reading cannot reach.
Even more outrageous, in order to further reduce costs, insurance companies have developed AI systems to implement an assembly-line review mechanism.
The first step AI reviews is not the patient, but the doctor. Before providing certain treatments or services, the doctor must first send a request to the AI for review. Only after the review is approved can the doctor begin treatment. Even if the doctor believes that the patient's condition is critical, this step cannot be bypassed. Otherwise, the AI system will directly reject the claim.
In this way, the conflict that was originally between the patient and the insurance company was suddenly shifted to the doctor-patient relationship.
To avoid medical disputes and claims, doctors tend to conduct excessive examinations and provide conservative treatments, further increasing costs.
Drug pricing is even more brutal, because the government has no right to intervene in pricing, so pharmaceutical companies raise costs tenfold or even a hundredfold.
Insulin that costs a few dollars in Canada is priced at $340 in the United States, forcing diabetes patients to cross borders to purchase the drug.
After the patient receives treatment, the AI will conduct a second review of the patient's submitted claim to determine whether it is compliant and decide whether to pay accordingly.
Insurance companies claim that AI can improve efficiency, control costs, and ensure the appropriateness of healthcare services.
However, the specific operation and decision-making logic of AI algorithms have always been regarded as "trade secrets" by insurance companies, who refuse to disclose them to patients and doctors.
However, according to industry insiders, the so-called AI review can reject a patient's application in just 5 seconds.
The first second: Electronic medical record keyword scanning, which will trigger a large number of risk labels such as "obesity" and "aging".
3rd second: A comparison of the fluctuation model of treatment costs and insurance company stock prices.
5th second: Generate a denial notice containing 37 contradictory clauses. This notice is verified using a highly professional legal team and takes 147 days.
This led to the following bloody cases.
In Arizona, retired teacher Linda's smart insulin pump kept sending "good blood sugar control" data, prompting the AI system to terminate her reimbursement for continuous glucose monitoring.
Three months later, she died in a supermarket from undetected hypoglycemia, and the $28 cost of her last-minute resuscitation was still ruled as "negligence in her own health management."
In Florida, construction worker Carl's application for knee replacement surgery was rejected seven times. The AI annotation stated: "Manual laborer's expected working years after surgery are insufficient to cover cost recovery period."
After he underwent surgery at his own expense, the system immediately added him to the "high-risk insurance fraud list" and banned him from insurance for life.
In California, the widow of a programmer received 463 emails from AI demanding compensation. The system accused her husband of "deliberately concealing the decline in his immune system caused by staying up late" based on data from his smartwatch.
At a rally for healthcare debtors in Houston, people held up insurance policies torn up by AI and chanted, "Our heartbeats aren't binary; our lives refuse to be compiled!"
Where there is oppression, there is resistance. When AI, which was originally meant to serve humanity, becomes a killing machine, there will inevitably be people who stand up and fight against it.
Luigi, an Ivy League graduate, shocked the nation by purchasing a ghost gun online and shooting and killing Brian Thompson, CEO of UnitedHealth Group, on the streets of Manhattan, New York.
This company is a behemoth in the health insurance industry, not only selling health insurance to external parties, but also owning chain pharmacies and hospitals through mergers and acquisitions.
However, as an industry leader, UnitedHealth's rejection rate is as high as 32%, which means that one in three patients will be denied medical reimbursement.
Police found multiple 9mm bullet casings at the shooting scene, marked with words like "delay" and "reneging," a common practice among American health insurance companies to evade claims, a practice widely criticized.
Subsequent investigations revealed that the gunman had suffered from back pain since childhood due to anterior spinal displacement, which worsened after a surfing accident. He underwent spinal surgery and his condition improved. The motive for the murder was "suspected" to be related to UnitedHealth Insurance Company, where the victim worked.
The victim, Brian Thompson, earned over ten million dollars a year, and the company's profits climbed from 120 billion to 160 billion during his tenure.
Such huge profit margins are directly equated with ever-increasing rejection rates, leading to a large number of patients falling into poverty due to illness, falling into a vicious cycle, and ultimately being forced to become homeless.
Even worse, some patients may die from delayed treatment, and their future and lives are all exchanged for money, villas, luxury cars and yachts.
Logically, such a heinous murder should have caused public outrage and lamentation, but public opinion has overwhelmingly turned against the killer.
Many people call him the "real-life Batman" and the "modern Robin Hood," and some even get tattoos with his photos. Some girls have even posted on social media that they "want to marry him."
When the police department and the FBI issued a warrant for his arrest, citizens all over New York City were working to create alibis for Luigi.
Because he shares a name with Mario's best friend in the game, netizens have even accused him of being "the real culprit, not Luigi!"
A top female lawyer with thirty years of professional experience defended Luigi, removing the most serious charges and successfully saving his life.
More pragmatic people are already inquiring about the bail amount and preparing to crowdfund for their hero.
And this is why the US healthcare system, which it is so proud of, spends the most money but saves the fewest lives.
Given this context, it's perfectly normal that Jimmy's mom was denied insurance coverage by the insurance company; after all, this cut would save the company several thousand dollars.
Although insurance contracts usually set a deductible limit based on the insured's circumstances, for example, if your deductible limit is $5,000, then no matter how much you spend on medical treatment this year, you only need to pay a maximum of $5,000. Even if you spend another $500 million, it has nothing to do with you.
However, there is no uniform standard for this out-of-pocket expense limit; it is relatively low for healthy people, but much higher for those who are sick.
After careful calculation, Jimmy discovered that in order for his mother to continue receiving treatment in the hospital, he would have to pay at least an additional $2.5 in out-of-pocket expenses each year.
For a young man like him who was unemployed and whose main occupation was still collecting recyclables, this was an absolute hellish challenge in his life.
"Sir, I mean no harm, but I still want to ask, what will happen to my mother if I fail to pay off the debt within the stipulated period?"
After hesitating for a while, Jimmy finally mustered up the courage to ask.
Dr. Horton shrugged helplessly: "Son, if you want to hear the truth, then I'll tell you. First of all, your mother won't be left on the street, but the hospital will urge you to pay off the debt. There's usually a window of opportunity. If you still haven't paid the bill by the final date, the hospital will downgrade your mother's care level, reduce the doctor's consultation time, and even cut costs by changing medications. This is quite detrimental to the patient's recovery."
"Once this happens, the insurance company will quickly intervene and further reduce the payout amount on the grounds of ineffective treatment or deliberate delay in recovery. Then, your mother will be sent to a mental health care facility run by the government or a non-profit organization, and social workers will monitor her 24 hours a day. But you have to understand that there are no doctors, no nurses, no systematic treatment, and they only take care of her daily life. If the patient has abnormal behavior, the only thing they can do is to use a belt to fasten her to the bed. Yes, it's the kind of scene you see in movies."
Hearing this, Jimmy painfully tugged at his hair: "Sir, give me some time, I'll find a way to pay off the debt."
"How long will it take?" Dr. Horton adjusted the glass frame on his nose. "You need to understand that you've been in arrears for two months. If it were an ordinary patient, the hospital would have already taken measures. But your mother is a union member, and she deserves special care both morally and logically. However, that doesn't mean the hospital can support her indefinitely. So I'll give you a maximum of one more week. Don't try to bargain with me."
"Okay, I'll do it as soon as possible." After promising not to delay payment, the kid temporarily put the debt problem aside and got to the point: "Can I go see my mom now?"
"Okay," Dr. Horton replied, "but you'd better be prepared, because your mother hasn't been doing well lately and may exhibit some unusual behaviors. What you need to do is listen, understand, and be tolerant. Don't argue with her, because her thinking is very confused right now. You can't treat a patient like a normal person."
"Yeah, I understand." Jimmy nodded helplessly, trying to reassure himself.
Led by the nurse, the two finally entered the ward where Jimmy's mother was staying.
The first thing Ma Jieke saw was the profile of a beautiful woman with no makeup, wearing a pink striped regular hospital gown, quietly reading a paper book while leaning against the headboard.
Warm sunlight streamed through the blinds, illuminating the entire ward brightly. Several small, tender green potted plants on the windowsill added a touch of life to the space.
"Hey Mom, I've come to see you. How are you?" Jimmy tried to make his voice sound cheerful as he eagerly walked toward the hospital bed.
Attracted by the voice, the woman closed her book, hopped barefoot onto the floor, and her previously calm face instantly broke into a smile as she stretched out her arms to greet him: "My child, oh my goodness, my poor Jimmy, I'm so happy to see you! When did you grow so tall?"
Just as Jimmy was about to hug his mother, she simply scurried past him like an obstacle.
Before Ma Jieke could react, she hugged him tightly.
The accompanying nurse, upon witnessing this scene, instinctively covered her mouth, her eyes filled with terror.
Jimmy stood motionless, as if he were staring at Medusa, his arm still suspended in mid-air.
But Margaret clearly didn't care about any of that. She gently stroked Majab's face with her palm, her eyes full of maternal love: "Good, it's good to grow taller. That way, you won't be bullied when you're out there. Look how strong you are now. Come on, tell your mother how you've been lately. Have you met any new girlfriends?"
Ma Jieke was completely dumbfounded. He had imagined the worst-case scenario, but he never expected his aunt's condition to be this serious.
After thinking for a few seconds, he quickly pulled Margaret to Jimmy's side, thinking that perhaps she was just confused for a moment.
"Hey handsome, are you Jimmy's friend?" Margaret greeted him naturally. "Thank you for coming with him to visit me. It must have been quite a journey all the way from Los Angeles to a place like this. Not only did he encounter the evil forest witch, but also the golden lion beast and the cyclops. But it's okay, Jimmy will transform into a fire dragon at the crucial moment and defeat all the powerful enemies he encounters. This is the bloodline heritage that our dragon family is proud of."
"What, you don't believe me?" Before Jimmy could respond, the woman grabbed Jack and urged, "Come on, baby, show it to your friends, breathe fire from your mouth, like this, hiss... ha!"
Listening to his mother's rambling nonsense, Jimmy felt utterly hopeless. Although Dr. Horton had warned him before he came, he had no idea how to respond to such a cruel reality.
"Hey, what's wrong with you, kid? Forgot what your mom taught you? Now learn it from me, hiss...ha!"
Margaret deliberately hunched over and made sounds that mimicked a dragon breathing fire, making her look quite eerie.
"I'll go get the doctor." Seeing this, the nurse turned and walked out of the ward. For medical staff, this was also their duty.
Under the woman's eager gaze, Ma Jieke imitated her awkward posture and hissed.
The combination of sounds "Ha".
"Oh my god, don't be so reckless, kid. You almost burned your friend."
Margaret waved her arms twice at the air in front of Majac, as if extinguishing the flames, then looked at Jimmy with a smug expression: "See, kid, I'm not bragging. Hundreds of years ago, I was the revered Dragon Mother of the Dragon Clan. It's just a pity we lost the clan war and had to hide our identities and live like normal humans."
"That's right." Ma Jie nodded in agreement. "But with true friends, we can open our hearts..."
"Shh, don't talk, boy." Just as Majesty was trying his best to play along with her fantasy, Margaret suddenly changed her tone: "Oh my god, my stupid son, you've led the enemy here! Quick, find a place to hide, Mom will figure out how to deal with them!"
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