FIRE Health Insurance Concerns

[mikex]

Did anyone see this CBS segment on uninsurable people yesterday?

The "Uninsurables", CBS News Investigates The Tactics Used By Insurance Companies To Deny Health Coverage - CBS News

I think it goes all week. Basically, by one company, the guy was denied for such things as spider bites he's had . They said some companies look at credit records, interview neighbors, ask about your morals (!) all kinds of weird stuff. What I was wondering, is what everyone is finding when they try to get individual plans. Are the insurance companies really that paranoid about minor things like spider bites and such? What types of things have you found that they will deny your application for. This could affect my decision, even though I am healthy right now, I need to know, if I had surgery or a kidney stone, or the like, is that a death knell for an application these days?

On another note, I realized that you never see the health care insurance companies advertise on TV for customers, like there really is no need to compete with each other. Why is that?

 

[Rich_by_the_Bay]

Mike, if you're in a masochistic mood do a search on this board for health insurance. You'll be deluged with extensive discussions here with some very strong opinions.

As to your question, my experience after decades in health care is that reputable companies would probably not go over the top very often in the way you described. However, in more subtle and perhaps even more deleterious ways, some will nickel and dime subscribers, create unnecessary delays, and otherwise hinder the entire reimbursement process in what I believe is, at times, a deliberate effort to minimize payment, appeals, and other financially burdensome (to them) duties.

They (and sometimes their agents) will quickly point to some fine point in the contract which, even if legally valid, is of such detail and such jargon that an average Joe like us would or should be expected to find it difficult to fully understand. Underwriting is a whole other area where they are holding all the cards. The system has problems.

Contrast that to their efficiency in collecting premiums.

 

[REWahoo]

On another note, I realized that you never see the health care insurance companies advertise on TV for customers, like there really is no need to compete with each other. Why is that?

I've seen lots of cable TV ads for Assurant Health over the last few months. Also, our local paper last week had a flyer for United Health Care. Seems to me there are many more ads for individual health policies that just a few years ago.

 

[tangomonster]

I actually was sure that I would be denied coverage because I have asthma (a very mild case---only symptom is a cough and never had to go to the hospital with it, but asthma meds even for a few months out of the year can be extensive) and take an osteoporosis drug. Surprisingly, I was accepted by BCBS for a very high ($10K) deductible 9which was what I applied for).

DH on the other hand was denied because he had cancer 12 (!) years ago, takes some mild heart/cholesterol meds, and has neurofibromatosis (which can be a nasty, expensive disease but which only causes lesions on his skin (so is just a cosmetic problem). Denied by BCBS; insurance brokers advised us not to even apply anywhere else. There were no questions about lifestyle and general health---just past history. Fortunately, he was able to convert his United health insurance from his job.

And don't even ask how much it's gone up in the year since we retired!

 

[mykidslovedogs]

I actually was sure that I would be denied coverage because I have asthma (a very mild case---only symptom is a cough and never had to go to the hospital with it, but asthma meds even for a few months out of the year can be extensive) and take an osteoporosis drug. Surprisingly, I was accepted by BCBS for a very high ($10K) deductible 9which was what I applied for).

DH on the other hand was denied because he had cancer 12 (!) years ago, takes some mild heart/cholesterol meds, and has neurofibromatosis (which can be a nasty, expensive disease but which only causes lesions on his skin (so is just a cosmetic problem). Denied by BCBS; insurance brokers advised us not to even apply anywhere else. There were no questions about lifestyle and general health---just past history. Fortunately, he was able to convert his United health insurance from his job.

And don't even ask how much it's gone up in the year since we retired!

If you've had a history of cancer, try World Insurance. Depending on the kind of cancer it was, they seem to be more lenient, and will look at apps if it has been five years since any symptoms or treatment. I'm not sure what all states they are in, but you might check to see if they do business in your state.

 

[mikex]

I've seen lots of cable TV ads for Assurant Health over the last few months.

Assurant - funny you should mention that company:

When Health Coverage Doesn't Hold Up, CBS News Investigates How Individual Health Insurance Providers Can Deny Big Claims - CBS News

From the second segment:

Walking along a stretch of road last summer, 54-year-old Tod Smith felt an intense burning in his chest and tightness in his arm — signs of a heart attack he never saw coming.

"I was in good health," Smith said. "No major health problems or conditions."
For Smith, an illustrator of children's books, his heart attack was the first shock. The second: more than $40,000 in medical bills his insurance company refused to cover — after he figured the company, Assurant, would pay.

"I certainly figured that a heart attack was a catastrophic event. So I figured I was covered," Smith said.

A two-month CBS News investigation of the individual insurance market found that Smith's experience was far from unique. Because it was expensive, his claim was investigated for fraud by Assurant Health, his insurance company.

After examining his medical records, the company refused to pay based on a 3-year old-reference to an "angina episode." Assurant said those words proved his condition was pre-existing, despite the fact that follow-up tests in the same file diagnose his "episode" as a case of acid reflux and ruled out a heart condition...

... CBS' investigation of Assurant found a pattern of questionably denied claims and cancelled policies — and what a South Carolina judge called a culture of "secrecy, concealment … and shredded documents."

 

[mykidslovedogs]

I wonder if that person tried to file an appeal with an indepent case review team. In Colorado, if the insurance company refuses to pay a claim, and if we feel that their reasoning is bogus, we take the claim to an independent review team assigned by the division of insurance that is unrelated to the carrier. They have the power to force the insurance company to pay the claim if it is legitimate. Anyways, that's the process I usually use when I run into a complicated one with any of my clients. Those kind of cases are few and far between.

CBS makes it sound like these things are a daily occurrance. I've been working in the industry for about 10 years, and I've only come across one or two that I've had to take to the division. Each time, the division upheld the decision.

On the other hand, I recently had a client who went in for elective surgery to fix a hiatal hernia. He ended up with a staff infection and racked up over $1,000,000 in claims after having been hospitalized for the good part of a year. He was very thankful that he had the coverage.

 

[mikex]

On the other hand, I recently had a client who went in for elective surgery to fix a hiatal hernia. He ended up with a staff infection and racked up over $1,000,000 in claims after having been hospitalized for the good part of a year. He was very thankful that he had the coverage.

Yes indeed, that is why we need health insurance, I'm glad they paid, but how do you know in advance they will pay?

I've been doing a lot of reading lately.

USATODAY.com

From that article:

The newest tool insurers have found is to check into every sick person who files an expensive claim to see if there's an argument that they lied on their enrollment application," says Jamie Court of the Los Angeles-based advocacy group Foundation for Taxpayer & Consumer Rights.

The health insurance company should investigate your medical history, OK. The can deny your application or accept your application after they finish the investigation - OK. But - at the point they finish the investigation, and of their own buisiness decision then grant you a policy, it should be certified as being investigated fully. They have had their chance to investigate, and they cannot go back again and dig up more dirt. This should be a legal requirement to certify it as a completed investigation, because they had full and free means to either accept or deny the data.

 

[mykidslovedogs]

I've been doing a lot of reading lately.

USATODAY.com

From that article:

The newest tool insurers have found is to check into every sick person who files an expensive claim to see if there's an argument that they lied on their enrollment application," says Jamie Court of the Los Angeles-based advocacy group Foundation for Taxpayer & Consumer Rights.

The health insurance company should investigate your medical history, OK. The can deny your application or accept your application after they finish the investigation - OK. But - at the point they finish the investigation, and of their own buisiness decision then grant you a policy, it should be certified as being investigated fully. They have had their chance to investigate, and they cannot go back again and dig up more dirt. This should be a legal requirement to certify it as a completed investigation, because they had full and free means to either accept or deny the data.

I'm not advocating every decision insurance companies make, but a good portion of the approval process is based on the information that is supplied on the application. Probably about 60% of the time, medical records are not ordered, because of number one, the cost involved in getting them, and number two ,the time it takes to get them. If insurance companies pulled detailed medical records for every person that applies, it would take forever to get applications through underwriting. Therefore, they depend on the accuracy and validity of your disclosures. I've been doing this for a number of years, and I've had a few customers who purposefully failed to disclose a pre-existing condtion on their application and were later rescinded of coverage because of that. One of those people was even a lawyer (can you believe that!)...and when confronted, she admitted she left the information off the application.

I think it's only fair that insurance companies be allowed to investigate expensive claims, especially if they happen within one or two years from policy inception. A lot of times, people wait to purchase insurance until they feel that they are at high risk for a claim. Let me give you an example. I once had a client who wanted to buy insurance for his son who had a large lump on the side of his face. He didn't disclose that fact on the application. While the app was in underwriting, the client got upset because his son needed surgery to remove the lump, but he hadn't been approved yet. That person also had a large gap in coverage, and had never carried insurance on his son, and didn't even think aobut buying it until they needed it. I told the client that I could not persue the application any further because of the failure to disclose the lump. I explained that there would be an investigation anyway, and likely the claim would be denied.

Based on my experience, I think it happens more often that people will purposefully fail to disclose something than the insurance company not paying for something. That's just my opinion. I'm not saying that insurance companies are never wrong. I just think it is within their rights to be able to do deeper investigations of medical records if necessary.

 

[mykidslovedogs]

Another point to add on to the above. If you think that you can't remember everything that you need to put on your application, it is in your best interest to order your own med records and supply them along with your application as part of the contract. That way, the insurance company will have everything they needed as part of your contract, and they won't have a leg to stand on if they try to deny something later on as "pre-existing".

 

[mikex]

Another point to add on to the above. If you think that you can't remember everything that you need to put on your application, it is in your best interest to order your own med records and supply them along with your application as part of the contract. That way, the insurance company will have everything they needed as part of your contract, and they won't have a leg to stand on if they try to deny something later on as "pre-existing".

Thanks for your response.

Well, if the medical records will keep everyone honest, which I agree with, then why not make it a requirement that the applicant has to supply them copies, wouldn't it make the whole system more iron-clad? You supply your medical history, and if the company accepts that and grants you a policy - game over, they can't deny your claims for any unknown pre-existing conditions because everything is above board. Is that too logical for the industry? Wouldn't that prevent lawsuits that just drive up the cost of health insurance for the mere price of having the records copied?

 

[mykidslovedogs]

Thanks for your response.

Well, if the medical records will keep everyone honest, which I agree with, then why not make it a requirement that the applicant has to supply them copies, wouldn't it make the whole system more iron-clad? You supply your medical history, and if the company accepts that and grants you a policy - game over, they can't deny your claims for any unknown pre-existing conditions because everything is above board. Is that too logical for the industry? Wouldn't that prevent lawsuits that just drive up the cost of health insurance for the mere price of having the records copied?

I TOTALLY agree with you! Problem is, Dr offices sometimes charge upwards of $50-100 dollars to give you a copy of your records, and many applicants don't want to pay the fee, so currently, a lot of carriers will pay the fee for records, just to get you to apply. Secondly, some people don't HAVE medical records, because they never go to the Dr. Are we going to require them to get a complete physical before applying and if so, who's going to pay for the office visit?

 

[FIRE'd@51]

I was turned down for health insurance and had to take a BCBS guaranteed-issue policy (with no health questions to be answered). Even though it costs a couple hundred dollars more a month than a similar underwritten policy, I must confess that I sleep better at night knowing that the insurance company can't fight a claim on the grounds that I didn't answer the health questions properly or completely, or that I inadvertently failed to mention something.

 

[mikex]

I was turned down for health insurance and had to take a BCBS guaranteed-issue policy (with no health questions to be answered). Even though it costs a couple hundred dollars more a month than a similar underwritten policy, I must confess that I sleep better at night knowing that the insurance company can't fight a claim on the grounds that I didn't answer the health questions properly or completely, or that I inadvertently failed to mention something.

I didn't know about that. Meaning you can't be turned down for coverage for any health issue? So your health condition that you were turned down for, is covered now - or excluded?

 

[FIRE'd@51]

I didn't know about that. Meaning you can't be turned down for coverage for any health issue? So your health condition that you were turned down for, is covered now - or excluded?

It is covered. In my state, Anthem BCBS offers a last resort guaranteed-issue policy to anyone who is a resident. There is a 12-month waiting period for pre-existing conditions which is waived if you are HIPAA eligible. It's a decent policy other than the cost, which is about twice the standard rate. In my case, my original insurance company, Mutual Of Omaha, exited the individual insurance business and canceled all of its outstanding policies. This made me HIPAA eligible, which meant any company who sells insurance in my state had to offer a me a policy at their HIPAA rate, which is their highest rate. It turned out that the Anthem policy was IMO the best one in terms of coverage and price.