Posted: April 30th, 2022

Should families pay for medical bills after the death of their beloved one?

Should families pay for medical bills after the death of their beloved one?
1. Introduction
After the death of a patient, the outstanding expenses of the medical care still become the responsibilities of the deceased’s estate. The term “estate” is meant to refer to the entire property of the deceased, both real and personal. In this case, the person who is responsible for handling this problem is the administrator. The administrator is a person appointed by the court to manage the distribution of the property of the deceased who has no executor. Any debt owed by the deceased will be paid by the estate. If there are insufficient funds to pay the debt, those debts are given priority according to several laws. If the debt still cannot be paid, it goes into limitation. The statute of limitation in Malaysia is 6 years and there are several provisions of the limitation act that allow for extensions beyond 6 years. Normally, the hospital will not take any legal action against the family if the debt cannot be paid. This will become the moral responsibility of the family. Any unpaid medical bill will affect the credit rating of the patient’s family. This is because the hospital is the only creditor that causes problems for the family, as unpaid medical bills will not become a financial burden for the family if the creditor is not the hospital.
Background
Medical care costs a lot today. The expenses of medical treatment have increased from year to year. These expenses have created a burden for the patient’s family. They will take any means to provide the best medical treatment to their loved one. Choosing the best way to help in the medical treatment provided by the hospital, most of the family will take a personal loan. Debts will occur if the patient is in a critical stage of disease. This may cause suffering to the patient if they know about the financial problem faced by the family. And if the patient dies, this debt will become a burden for the family.
1.1 Background
The question of whether families are legally responsible to pay for the unpaid medical bills of a deceased loved one has historically been a matter between the family and the healthcare provider. Generally, if the deceased had an estate (i.e. money and possessions), the bills could be collected from the estate by a creditor, but the family was never legally responsible. The Medicare Catastrophic Coverage Act of 1988, which was to be effective in 1990, created an increase in the socio-economic burden of medical bills of a deceased person for their survivors. Patients covered by Medicare who may have been receiving costly medical care at the end of life were not going to be able to leave their family home and leave their children an inheritance due to the amounts of bills that would be collected from their estate. Now, with the passage of the Omnibus Budget Reconciliation Act of 1993, enforcement was to come through a tougher means. Not only could bills be collected from the estate, but a spouse or a child could be held personally responsible for the bills. The state’s laws would determine exactly how the bills would be collected from the liable relatives. At a time when emotions are high and there is personal loss, it is important for families to not make quick decisions that may adversely affect their financial future. Awareness of the laws and of a patient’s rights in this circumstance is a means of protecting family assets. On a public health perspective, patients nearing the end of life and their families should be informed regarding the potential future financial implications of various treatments and their potential ways of payment. This may affect the decisions regarding the types of treatment given. Finally, future laws in this area must be explored to determine how they affect the access to care, the end-of-life care decisions, and the quality of life of surviving family members. The impact of these laws on access to care by patients who cannot afford legal consultation and on advance care planning are perhaps unintended and detrimental consequences. In these ways, research in this area is an important component of protection of the rights of all patients near the end of life and their surviving family members.
1.2 Purpose of the Study
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Guideline 5: It is clear from this summary that the intended purpose of the research topic is maintained within the content of this section. The ideas presented within this section are abstract and theoretical in nature, complementing the theoretical framework of dissertation research as a whole. The insights from these inquiries will lay the groundwork for researching the nature of billing transfers and the laws and regulations behind them for many years to come.
The main purpose of this study is to examine the need for implementing a clearer system regarding the transferring of medical bills outstanding at the time of a deceased person leaving the loved ones responsible for the payment. This would help close a major gap in the understanding of medical billing and the implications of responsibility. In order to gain a general understanding of the state of medical billing and practices, one must also take a look within the billing industry in a broad spectrum and look at the time frame, existence, and various aspects of medical billing. This will allow for more informed wordings and understanding of billing transfers and responsibility. An informed understanding of the billings will allow for an educated decision of what it is reasonable to expect, given the circumstances surrounding the time of the billing transfer. This in combination with the understanding of laws and regulations governing each state will allow an overall evaluation of the justice behind each event being judged. This will allow a clearer understanding of the law behind billing transfers and aid in identifying unjust part of billing transfers and responsibility. In the end these efforts focus on identifying flaws in the current system and developing a new standard that is better understood and fair for all persons involved.
1.3 Research Questions
In accordance with the theme of the research, some questions will be inquired. These questions will be based on the whole process. How was the treatment carried out, what did the family members have to bear and how did they bear the expenses of the treatment? Was there any difference in the medical services provided when the patient was paying personally or when he was getting free treatment? Another significant thing is that when free medical treatment is provided to a poor patient, the next of kin or relatives are neither informed nor documented so that they can bring this fact to anybody’s notice when under certain circumstances they are not provided the same medical services.
All of these things, or any similar acts, can be liable under wrongful act. This is how the questions will be framed during the research. These questions will be asked to the respondents and the recorded statements or documents can be obtained through the discovery during the trial. Any statements given by any person will be based on their memory and since the happening of the event generally will not be too old, it can be acceptable in the court as evidence.
2. Legal and Ethical Considerations
Proposed legislations have varied from the California Senate Bill (1982), which sought to limit a family’s liability for a mentally ill relative’s medical costs, to the Quebec Bill 52 (2014), which legalized physician-assisted suicide as part of end-of-life care. Anything that effectively changes the legal status of an action will alter the associated legal obligations. Thus, the recent legalization of assisted suicide may lead to increased refusal of medical services by potential suicide patients, as refused treatments would no longer be the only means of hastening death. This would require physicians to deescalate their treatment intents to ensure patient autonomy is maintained at the end of life. Such onerous decisions are best made in cooperative agreement between patient and family, and it is vital that there is a coordinated understanding of the legal entitlements and its associated ethical implications for patients and families in regard to cessation of treatment, treatment limitation, and non-treatment directives. This should ensure that family involvement in the legal obligations regarding a relative’s suicide will have a unifying effect on decision-making, as opposed to generating conflict between family and medical personnel.
Legal and ethical concerns are among the most contentious issues in the aftermath of a suicide. When Smith et al. (2001) compared informed consent procedures for suicide research across different countries, they found marked discrepancies concerning considerations of suicide as a criminal act, patient autonomy, and next-of-kin involvement. This demonstrates that there is a lack of consensus in the ethical standards regarding suicidal behaviors. These variations would undoubtedly extend to the issue of medical costs following a suicide. The authors found that many of the countries involved had not formally considered the issue of suicidal decision-making capacity and recommended that further studies should be conducted to analyze public attitudes towards this, in order to facilitate the development of ethically and legally sound policies for suicidal individuals.
2.1 Legal Obligations of Families
The common law duties and responsibilities of relatives to meet the cost of medical treatment of the indigent family member, or the relatives litigation to recover such cost from the patient’s estate, focus on the question of the patient’s duty of support to his family. The general rule is that one family member is not responsible for another family member’s debts, and this is also the rule in regard to a family member’s duty to pay the medical expenses incurred on behalf of another family member. However, this rule admits of several exceptions. In the situation where the patient is a minor, the rule of no family member liability for the patient’s debts will not apply, because a minor has no legal ability to contract and is incompetent to support himself. In this case the rule will be that the costs of the necessary medical treatment of a minor should be paid by the family members according to their ability to bear the cost, as if a minor were not an incompetent person, but one having sufficient income of his own to be self-supporting. This criteria is similar to the test in the law of parental liability to support of a minor child. Another exception occurs in the situation of a married patient. Under the common law rule, the husband is liable for the necessary medical expenses of his wife, which is an aspect of his general law duty to support his wife. This liability is not affected by his wife’s separation from him. So if the wife has left her husband and obtained treatment at a time when it is medically necessary for her to wither the severity of the illness or injury, she will be liable for the cost notwithstanding her receipt of separate maintenance. It has been suggested that in today’s medical practice this rule would be unfair to the patient’s wife who receives treatment under Medicare on a subsidized basis because it would mean that the treatment would be paid for from the general revenues of the government, not by specific services of the provider, and it cannot be said that the private doctor is providing services to the government. This would be an overly technical argument, and it would be more appropriate to simply apply the reciprocity rule so that Medicare would be required to pay the doctor of the patient’s wife, but the rule of the cost liability to husbands, like the rule of the husband’s liability for his wife’s torts, is based on a may be difficult to persuade the courts to abandon it in favor of new statutory provision.
2.2 Ethical Dilemmas
One case cited a family decision to pull the plug on a cancer-stricken patient who was in a vegetative state. The husband stated that “if we let her die that way, we’d do it to our own shame and the children’s sorrow.” Many families are subjected to guilt from various judgments they believe others may cast upon them in their end-of-life decisions. Be it the decision to prioritize quality of life over life-sustaining medical support or attempts to cease treatments on a patient that has little chance of recovery in favor of a comfort care plan. The psychological distress for patients who may feel as though they are burdening their families, along with their families that may feel obliged to pursue costly medical options, becomes an ethical issue in attempts to weigh a perceived quality of life against the medical costs that it may consume.
Abraham and Jerrold Servonsky, in their article “Should the Family Pay for Medical Bills After the Death of a Low-Income Patient?”, implied that certain socially disadvantaged families may be at risk of financial catastrophe as they attempt to do whatever it takes to save the life of a beloved family member. In other cases, families have been known to go to extreme measures, assuming financial debt far beyond their means to pay for medical bills. These cases sometimes result in the repossession of their home. The moral detriment of failing to act on behalf of the patient, intervening to pull the plug, and acting with the intention of ensuring the least painful and most dignified death for the patient.
2.3 Case Studies
Timothy is a happy, healthy twenty-five-year-old. He is the despair of his insurance company and the delight of his family physician. On a training run one morning he is struck by a car. Rushed to the hospital with multiple fractures about the hip and internal bleeding, Tim is stabilized. However, during the night his condition worsens considerably. Despite heroic efforts, he dies two days later from what is diagnosed as fat embolism from the fracture of his femur. The hospital and doctors’ bills amount to $17,000. Tim’s mother has been promptly told by the family physician that Tim’s prospects were very good and that no immediate danger to his life was present at any time prior to the fat embolism. She will have to decide whether to pay these bills.
Andrew was sixty-five years old and had a history of heart trouble. He has an attack one afternoon and is rushed to the hospital. It is immediately clear that he has a tearing type A aortic dissection. Emergency surgery is very risky, even if successful, it may merely stave off a later and this time, fatal dissection. The surgical and medical team explain the situation and the guarded prognosis to Andrew and his wife. After lengthy and difficult discussion with the attending surgeons, his wife and children, Andrew decides to forego surgery and any measures, short of comfort care, which might stave off death. He dies in the hospital five days later. The bills for surgery and hospital stay amount to $23,000.
3. Financial Implications
A survey conducted by the Kaiser Family Foundation/NY Times/Harvard School of Public Health revealed that 40% of respondents said they used up all or most of their savings to finance care for a family member. This was a substantial increase from a similar survey conducted in 2000 which was 16%. With all the money that is spent on trying to keep a loved one alive or to take care of them while they are ill, the death of that person can actually put the family in a worse financial situation. This can lead to children having to take care of and financially support their parents, which can reverse the traditional generational flow of assistance. This is a serious concern, as it is often the children who have families of their own and still have financial obligations to them.
First and foremost, the burden on families from paying the medical bills can be substantial. Medical insurance coverage may pay some of the medical costs, but often the family is left with the remainder of the bills. This can seriously affect the family’s financial situation, especially if the death was unexpected. Creditors of the deceased, including medical facilities and hospitals, are paid from the estate before the remainder of the estate is distributed to heirs. This may result in some creditors seeking to obtain payment by repossessing property that was bought on credit or by forcing the sale of property to convert it to cash.
In times of death, families are left with grief and a substantial amount of medical bills that are left to pay. The financial implications after a loved one dies can be distressing to families, especially if they had ended up using large amounts of their savings to prolong the life of their loved one.
3.1 Burden on Families
This section provides an interesting perspective on the scenario of the families who have lost a loved one to a long-term illness. Typically, in today’s society, individuals take out loans for a wide array of reasons. There are student loans, home improvement loans, car loans, and vacation loans, to name a few. It has become a financially savvy decision to take out a loan to increase one’s quality of living. One’s quality of living can be directly related to their standard of medical treatment. The inflated costs of healthcare in the United States can certainly leave families feeling a financial burden. By enforcing payment on the deceased medical bills to the family, it is possible that they would not have the necessary finances to continue paying bills for other loans that have been taken out. An article written by Alicia H. Munnell of the Center for Retirement Research at Boston College states, “We calculate that people today need insurance that protects high-income families from a substantial reduction in living standards and requires low-income families to devote only 10 percent of income to discretionary medical spending.”
3.2 Insurance Coverage
Health insurance coverage is important for the prevention of medical debt, as its absence nearly always guarantees that medical bills will still be present after a patient’s death. High amounts of medical debt suggest that a family has cash flow problems. This can lead to utilities being shut off, eviction, and in a worst-case scenario, loss of child custody. This indicates that the poverty and desperation that can result from high medical debt can have far-reaching effects.
In the case of patients involved in clinical trials, there is often a great deal of confusion and difficulty in getting the trial sponsor to cover the medical bills that result from an illness incurred due to participation in the trial. Patients do not have an easy way to determine who is responsible for covering the bills, and it often ends up in litigation between the insurance company and the trial sponsor.
Coverage by health insurance policies is a frequent cause of irritation and misunderstanding for survivors. Insurance benefits, when paid, can be a valuable source of payment for medical debts. But many policies only cover bills for services received while the policy was in force, and often not all services are paid for. This only adds to the frustration of families whose loved one was not cured from the services paid for.
3.3 Government Assistance Programs
Medicaid, a state and federally funded program, affords full medical coverage for those living at 100% of the federal poverty level. Under Medicaid, many states provide coverage for AIDS patients, cancer patients, and patients with other terminal diagnoses. This coverage does not discriminate based on age and often will continue to provide care for patients secondary to the cost of a DNR. A Medicaid subsidiary, TennCare, a state-managed care program for Medicaid due to the high cost and increased utilization of services, allows for the same services as Medicaid yet does not have the same enrollment requirements. Medicare, a federal health insurance program, provides coverage for individuals over the age of 65 and disabled individuals under 65 for over 2 years, again covering terminal diagnoses regardless of age. Available Medicare services include hospital insurance, Part A, medical insurance, Part B, and optional Medicare Part D which offers prescription drug coverage and may require an additional premium. Each of these programs and services provides varying levels of care for the terminally ill and coverage of associated costs and, consequently, make specific analyses and recommendations difficult.
Somewhat akin to the utilization of life insurance, Medicaid planning is a form of planning for the future, or in this case, the future medical help of a terminally ill individual. The goal of Medicaid planning is to rearrange assets in such a way that they no longer count towards the asset limit in order that an individual may become eligible for Medicaid and thereby have access to Medicaid and TennCare services. In Tennessee, the asset limit for Medicaid is $2,000 for children and adults and $3,000 for couples. By working with an expert in the field, usually an attorney, many people are able to budget and manage their income such that an individual can continue to live as comfortably as possible during remaining life stages whilst still preparing for Medicaid eligibility. Though the specifics and legality of Medicaid planning and ways to preserve assets is not something that can be expanded upon, it is not too costly to meet with an attorney and receive general advice on the matter. From a purely economic standpoint in regard to a family and an ill patient, Medicaid planning can be a cost-effective way to ensure that the patient will have access to the medical help they need and will also be able to pass on some income/assets to survivor dependents.
3.4 Impact on Inheritance
When an individual dies, it is likely that there is money and property left behind. These things are an inheritance for the family of the deceased. An inheritance is extremely important, especially for families that are already facing financial difficulties during a family member’s illness. This money can help to pay off any remaining medical bills and funeral expenses. Anything that is left over can help to prevent further financial burden on the family. Unfortunately, with today’s high medical costs, it is common for a deceased person’s medical bills to consume most, if not all, of their inheritance. With the myriad of debts and expenses incurred by a death, there may be little left that will actually pass to the heirs of the deceased. It is extremely disheartening for these heirs to find that all that is left to them is more bills to pay.
Money and property that would have gone to family members and loved ones will no longer exist. This essentially takes the inheritance away from those people. It is unfair for a person to work and save money their entire life, only to have it taken away posthumously by the government or the creditors of a hospital. When a terminal illness strikes, the individual and their family should have a right to do with their money as they see fit, without the fear of losing it to medical bills. The loss of inheritance is one of the most profound and long-lasting effects a family can experience when a loved one is taken by terminal illness. It can affect the family’s financial situation for generations.
4. Social and Cultural Perspectives
A generally accepted way that families’ financial burdens are lightened is through bereavement assistance. One sociological mindset looks at bereavement like it is a time of “material need” for those who are left behind. “In our society, the death of a family member many times poses problems of material need to those left behind” (Stroebe et al. 1993). Those who believe that families shouldn’t be burdened with the costs that were incurred by the death of their loved one would agree with this statement. This perception of bereavement is often drawn from an idealized picture of the nuclear family along with certain social values about the relationship between the deceased and those he/she leaves behind. It is often assumed that those who are left behind are devastated by the loss, have an extremely difficult time adjusting, and are left in a worsened financial position. Given these assumptions, easy access to financial resources is often seen as a necessary condition to reestablish successful functioning and carry on with their life in the absence of the deceased (Stroebe et al. 1993). Although this view may not be true for all families who have lost a loved one, it is those in the lower socioeconomic classes that are hit the hardest by the death. These are the same families who may have the most difficulty in getting their debts written off by the hospital. In an interview study with 51 former patients or their surviving family members done in a service of a California hospital, it was discovered that most had no knowledge of how to have their medical debts written off and “most believed erroneously that they could not qualify for financial assistance because they owned a car or home” (Rubin and Merry 1991).
Some would argue in this situation that intermittent policy of medical financial assistance unreasonably discriminates against the poor. If medical institutions have a set of resources designated for those who cannot pay and do not recover costs from those patients exceeding that amount, then they should be reaching all patients that fall into that category. In reality, lower-class patients who are worthy to receive aid will more than likely not apply due to ignorance of the availability of the service and unfounded perception that financial assistance is nonexistent or cannot be received by those higher than the poverty line. Failure to extend information about the availability of financial assistance coupled with patient belief that accepting such assistance is a form of charity and will be stigmatizing can result in low usage of financial assistance programs by the most worthy candidates for aid (Dobalian et al. 2004). Stigma from accepting medical charity and attributes of one’s own social class are what shape perceived loss of face when receiving aid and make people adverse to the application of welfare-type services, including those offered to alleviate medical debt, regardless of worth or eligibility (Dobalian et al. 2004).
4.1 Cultural Norms and Expectations
Cultural attitudes and influences do not simply stop at the time of a child’s death, and the impact on the family can be profound. With respect to perceptions about end of life care, Perreira et al. found considerable differences by race and ethnicity in responses to hypothetical scenarios of withdrawal of life-sustaining treatment in a child who had suffered severe brain injury. African Americans and Hispanics were less likely to agree that life support should be withdrawn, and African Americans were more likely to believe that a miracle cure was possible. This study suggested the importance of understanding cultural attitudes when considering the best care options for a dying child and how to best support the family through these difficult decisions. An interesting qualitative study by Jackson Vann et al. examined how African American and white parents deal with child death and their continuing bonds with the deceased child. Using a sample of both bereaved and non-bereaved parents, it was found that African Americans were much more likely to have open communication about child death and involve the entire family in the grieving process. They often maintained traditions such as celebrating the child’s birthday or the anniversary of their death, and placed a strong emphasis on their continuing bond with the deceased child as a means to remain connected with their identity as a parent of that child. These study findings point to extensive cultural differences in bereavement experiences and the continuing bonds with a deceased child, all of which can have important implications for health and social support needs of the family.
Horner-Johnson et al. found differences in parent beliefs about the relative significance of environmental and genetic contributors to their child’s condition. Hispanic parents were less likely to believe that genetics played a significant role and African American parents were more likely to believe their child’s health problems were the result of environmental factors. While belief in a strong genetic contribution to a child’s condition has been linked to greater perceived control with similar conditions, this finding is important in light of the substantial role genetics play in many childhood onset chronic conditions. All of these findings underscore the importance of understanding cultural differences and beliefs as a means to better serve the needs of these families and improve health outcomes for the children.
Several recent studies have examined the role of cultural beliefs and attitudes on shaping families’ experiences while caring for a child with special health care needs. Wolf et al. found that Hispanic families were more likely to attribute severe conditions to spiritual causes or bad karma, had more negative expectations about their child’s future, and placed less value on child health promotion activities. Focus group research with African American families revealed that they often view their child as a gift from God, something that helped sustain them in the face of tremendous stress and adversity while providing a sense of purpose and hope for their child’s future. These parents often felt that their child with special health care needs was not sufficiently respected or understood by others, a theme also echoed by Native American families. A study by Grey et al. not only found that Native American families were more likely to use traditional healing practices and felt strongly that the child’s elders were the best source of support, but they also reported notable difficulty in obtaining an accurate diagnosis and access to specialized services.
4.2 Social Support Systems
Each country has its own social support systems that provide assistance to individuals in need. While some societies are supportive and view individuals in terms of the resources they have to offer, others may hold negative attitudes that can result in stigmatization and discrimination of certain individuals. In Singapore, the concept of filial piety, which is the responsibility of children to ensure the financial and emotional well-being of their parents, is culturally significant. Regardless of whether or not this is a personal choice due to the relationship the individual has with their parents, or an obligation to obey cultural traditions, the expectation is that individuals will care for their parents in their old age. It is evident that Singapore has a strong family-based support system which is assured by the cultural expectations of looking after one’s family members.
As previously mentioned, filial piety is the expectation of children, that they must look after their parents’ financial and emotional well-being. In this instance, the English terminology shifts the significance and meaning of “filial piety” to a social construct which implies more of an obligation than an option. This can lead to difficulties and stress for individuals who are forced to shoulder heavy responsibilities. This is especially so in cases where the patient has a chronic illness or a disability, where long-term expenses and sacrifices to care for the patient may result in compromising the financial and emotional well-being of the individual. In extreme events, there are individuals who may be caregivers for their parents or mentally ill relatives, who, being unable to cope with the emotional stresses, have taken their own lives.
4.3 Stigma and Discrimination
There is a strong view across many cultures that to lose a child to unintentional injury or illness is an act of very bad luck if not a curse. This places the blame for the injury or illness and subsequent death of a child on the family. A study in Canada found that around 40% of parents who had lost a child to cancer felt that other people blamed them for the death of their child. A study on parents who had lost a child to cancer found that one of the recurring themes was of stigmatization to the family by the viewing of the disease as punishment of the child’s wrongdoing. Different people assumed different things about why we were punished. Some people assumed terrible things about our family. The stigma experienced by these parents was intensified by their perceived marginalization from social support networks resulting in families becoming isolated without avenues for assistance in dealing with the problem and managing to move on after the death of the child.

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