Pre-existing conditions and underwriting

[rwwoods]

My wife must find an individual medical policy that is underwritten. Given that there are pre-existing conditions, I understand that some insurance companies may be more likley to insure her than others. If that is true, which carriers should we investigate? A carrier that has been recommended by one agent is Golden Rule.

 

[sgeeeee]

I would try more than one. When DW and I had to find insurance to take us into retirement, we researched and applied for coverage from 3 different companies: Blue Cross/Blue Shield of AZ, Humana, and Golden Rule. Here's what happened.

BCBSofAZ offered insurance but wanted to exclude anything related to hernia surgery that I had 2 years prior to applying.

Golden Rule took up a lot of my time with the application, phone calls and questionaires, but then apparently forgot about doing the underwriting. I actually applied much earlier than the timeframe they claimed they needed for underwriting. Eventually, I was reaching a deadline when my work provided insurance would expire without getting a decision from Golden Rule. When I called them, they said they wouldn't be getting to it for another month or two, but that they would be happy to sell me a (very expensive) bridge policy to cover those months until they could get the underwriting task done.

Humana offered the policy they advertised and the rate they advertised.

Of course the policies of the three companies were not identical, but they were similar (catastrophic coverage, high deductible). Golden Rule actually advertised the policy that I preferred. That doesn't do much good if you can't really get it.

 

[mykidslovedogs]

My wife must find an individual medical policy that is underwritten. Given that there are pre-existing conditions, I understand that some insurance companies may be more likley to insure her than others. If that is true, which carriers should we investigate? A carrier that has been recommended by one agent is Golden Rule.

It really depends on the kind of pre-existing conditions she has. Every carrier has their own, unique underwriting guidelines. Some carriers will cover your pre-existing conditions, but charge you a higher rate than preferred. Other carriers may exclude pre-existing conditions from coverage, but charge you the original rate they quoted to you. The final possibility is that she could be declined for coverage all together.

If you give me an idea of the pre-existing conditions, I might be able to make some recommendations to you. BCBS tends to rate, while Golden Rule tends to exclude. Also, if you have any pre-existing conditions with Golden Rule, you are not going to get the preferred rates that are quoted by the quoting engines on the internet. Instead, you'll get a rate that is "standard" or higher, depending on the conditions. It could be 10-20% or so higher than the quoted rates. Humana tends to stick to the quoted rates, but exclude certain conditions. However, if the person applying is overweight, they can get rated by any carrier for that. Another "gotcha" is if the applicant is overweight AND has other risk factors like HBP or high cholesterol and/or smokes. That combination can result in a decline...

Please elaborate on the pre-existing conditions that your wife has and I'll see if I can help you out.

 

[RASAP]

... Golden Rule tends to exclude. Also, if you have any pre-existing conditions with Golden Rule, you are not going to get the preferred rates that are quoted by the quoting engines on the internet. Instead, you'll get a rate that is "standard" or higher, depending on the conditions. It could be 10-20% or so higher than the quoted rates.

Hope you don't mind if I jump in here...

I just don't get it. If they exclude all pre-existing conditions, what's the difference to the insurance company between:

1. A perfectly healthy 50 year old male that qualifies for the best possible rate and,

2. A 50 year old male who is just as healthy except (for example) a bad knee that is excluded from any claims since it is a pre-existing condition?

It seems to me that the second guy should get a better rate than the first guy since the insurance company is now liable for one less knee.

 

[mykidslovedogs]

Hope you don't mind if I jump in here...

I just don't get it. If they exclude all pre-existing conditions, what's the difference to the insurance company between:

1. A perfectly healthy 50 year old male that qualifies for the best possible rate and,

2. A 50 year old male who is just as healthy except (for example) a bad knee that is excluded from any claims since it is a pre-existing condition?

It seems to me that the second guy should get a better rate than the first guy since the insurance company is now liable for one less knee.

I would seem so, but that's just how the underwriting is done. It's written in their underwriting guidelines as such. In order to get preferred rating, you can't have any excludable pre-existing conditions. In my experience, most carriers do their "rating" that way. It's just the way it is. I always tell people, don't take it too personally, it's just the way they underwrite.

 

[cute fuzzy bunny]

Theres probably some table showing a statistical probability that someone with one bad knee will develop a second bad knee...

 

[RASAP]

... It's just the way it is.

Yeah, it's their game and their rules and if someone doesn't want to play, I guess they don't have to. I just hate that uncomfortable feeling that we are at their mercy with no choices.

 

[cute fuzzy bunny]

Look at it from their perspective...lots of potential customers, and the only ones they want are perfectly healthy ones who never get sick or injured. And the way they're working it, its implausible for anyone to remember every detail of every medical situation they were ever involved with, so if you develop an extremely expensive medical condition, a little investigative work by a PI and they're out of the deal.

 

[maddythebeagle]

Yeah, it's their game and their rules and if someone doesn't want to play, I guess they don't have to. I just hate that uncomfortable feeling that we are at their mercy with no choices.

You do have other choices....continue to work with a group policy or lobby for universal health care.....

 

[mykidslovedogs]

You do have other choices....continue to work with a group policy or lobby for universal health care.....

Just think - with Universal healthcare, you'll have one plan to choose from, AND you'll get to pay MORE in extra taxes than you would have paid for your own healthplan.

 

[mykidslovedogs]

Look at it from their perspective...lots of potential customers, and the only ones they want are perfectly healthy ones who never get sick or injured. And the way they're working it, its implausible for anyone to remember every detail of every medical situation they were ever involved with, so if you develop an extremely expensive medical condition, a little investigative work by a PI and they're out of the deal.

Why is it that when people buy life insurance, they plan to buy it before they are terminally ill, and when people buy homeowner's insurance, they plan to buy it before their house burns down, and when people buy car insurance, they expect to buy it before they get in an accident, BUT, when people buy individual health insurance, they want the insurance company to pay for illnesses they had BEFORE they bought it? One would'nt expect that with any other kind of insurance, so why do people feel it is a crime for an insurance company to ask you to purchase your coverage before you get sick?

 

[HFWR]

Maybe because it's a rare bird who has NEVER been ill or injured?

 

[mykidslovedogs]

Maybe because it's a rare bird who has NEVER been ill or injured?

Being that I have been in this business for many many years, I can tell all of you that health insurance carriers really don't care much about injuries that have been completely recovered, and they don't care about minor illnesses. When it comes to underwriting, their biggest concerns are chronic illnesses requiring expensive medications (such that the cost of meds ends up being much more than the premium month after month), and they also really worry about uncertain risk, such as a cancer that might return or the risk of an upcoming surgery. In my experience, very few people fall in any of those categories (except as we get older and require expensive meds/care for cholesterol control, elevated BP, arthritis, and other chronic illnesses like diabetes.

I think the reason people expect to be able to get individual coverage even after they get sick, is because they have been spoiled with guaranteed issue coverage their whole lives, paid, for the most part, by their employers. If we didn't have employer sponsored health insurance, people would purchase their policies for themselves and/or their children at much younger ages (perhaps from birth) and keep them for life, just like they do with life insurance. I think the premiums would be a lot cheaper then, because people would have a much better feel for the actual cost of their care/coverage, so they would make smarter/more economical decisions about the types of plans that they purchase and also about the care that they receive.

 

[cute fuzzy bunny]

they want the insurance company to pay for illnesses they had BEFORE they bought it

If I had a dent in my car and then bought insurance and then someone ran into the same dent, I'd expect the insurance company to pay to fix that part of the car...

 

[mykidslovedogs]

Yes, but if your car had been badly damaged to the point that it couldn't run unless it was repaired, do you think the car insurance company would sell you a policy and then agree to pay for the damage that was already there?

If you had broken your arm 10 years ago, and then bought an individual policy (which would not be a problem with a history of a broken arm), and then if you broke it again AFTER buying your policy, the health insurance company would pay for that.

 

[cute fuzzy bunny]

Well hell, if my car was banged up that badly i'd have bought another one.

I think the difference (in general) is that most people were covered by some kind of insurance at some point, and most people consider their health (and insurance) to have some continuity...although insurers obviously dont like that idea.

The bottom line is that people often get sick, and they need good medical care when they do. And medical care for the uninsured is stupidly expensive and hard to deal with.

I'm smart and rich and uninsured and *I'm* pissed about what I have to deal with.

 

[sgeeeee]

Being that I have been in this business for many many years, I can tell all of you that health insurance carriers really don't care much about injuries that have been completely recovered, and they don't care about minor illnesses. . . .

Like much of what you say on this subject, that simply is not true. We know your agenda, but people have proven you wrong multiple times on multiple threads.

 

[cute fuzzy bunny]

Well yeah...Blue Cross denied me due to a funny very minor variance in a liver test from 5 years before that went away on retest, and never manifested itself in any disease. Ever.

So I guess they care a little bit about stuff that never happened.

 

[mykidslovedogs]

Well yeah...Blue Cross denied me due to a funny very minor variance in a liver test from 5 years before that went away on retest, and never manifested itself in any disease. Ever.

So I guess they care a little bit about stuff that never happened.

Did you send them the medical records showing that it tested normally later on? If they find an abnormal test result, they are always going to want to see medical records from a follow-up before they make an offer. Usually, you can re-apply with the follow-up medical records without a problem. Any broker should be able to help you with that. Just because you were declined once, doesn't mean they won't take another look later on..

For example, I once had a client who was declined because of her weight. As soon as she got a few pounds below the required guidelines, she re-applied and was accepted without question

 

[mykidslovedogs]

Like much of what you say on this subject, that simply is not true. We know your agenda, but people have proven you wrong multiple times on multiple threads.

Well - if you live in a state that forbids insurance companies to exclude costs associated with minor illnesses such as Acid Reflux Disease, then you could be declined, but that would only be because of the state mandates requiring the carrier to cover meds that cost more than the premium. In CO, if you have a minor illnesses like Acid Reflux, the carrier can still accept you for coverage, but exclude the condition, thus, they won't be on the hook for the cost of Nexium, which would cost far more than the average monthly premium for a 50 yr old male in the individual market.

So, I guess you got me there....you CAN be declined for a minor pre-exisiting condition, but most of the time, that only happens if you live in a state that forbids the insurance carrier from excluding the costs associated with just that condition. In states like that, you can bet they are going to decline if their only choice is to decline or accept, without having the option to exclude.

 

[sgeeeee]

Well - if you live in a state that forbids insurance companies to exclude costs associated with minor illnesses such as Acid Reflux Disease, then you could be declined, but that would only be because of the state mandates requiring the carrier to cover meds that cost more than the premium. In CO, if you have a minor illnesses like Acid Reflux, the carrier can still accept you for coverage, but exclude the condition, thus, they won't be on the hook for the cost of Nexium, which would cost far more than the average monthly premium for a 50 yr old male in the individual market.

So, I guess you got me there....you CAN be declined for a minor pre-exisiting condition, but most of the time, that only happens if you live in a state that forbids the insurance carrier from excluding the costs associated with just that condition. In states like that, you can bet they are going to decline if their only choice is to decline or accept, without having the option to exclude.

Wrong again, MKLD. You tell a good story, full of lots of details. It's just that none of them are true.

 

[mykidslovedogs]

Wrong again, MKLD. You tell a good story, full of lots of details. It's just that none of them are true.

Please give me some examples. The information I am posting here is correct, at least for my state. If you don't believe me, take a look at the BCBS underwriting guideline booklet:

http://www.anthem.com/member/co/f4/s0/t0/pw_ad080042.pdf

Every carrier has one of these booklets, and for the underwriter's use, the booklets go into much greater detail....telling the underwriters when they can make exceptions, how long a person must wait until a decision can be appealed, when medical records must be ordered to aid in decision making, etc.

I know that CA has laws on the books forbidding insurance carriers from excluding even minor conditions from coverage, and this is why, in CA, it is possible to be declined for minor conditions, especially if the cost of meds is expensive. For example....you can be declined there for:

1.) Acne -- due to the possible risk of needing to take Accutane, which costs about $400.00 or more per month.

2.) Osteopenia -- due to the risk of needing to take Boniva, which costs about $300.00 per month

3.) Acid Reflux or GERD - due to the risk of needing to take an expensive med like Nexium or Protonix (running approx $200.00/mo).

In my state, these conditions CAN Be excluded from coverage, or the carrier can choose to rate a person higher to compensate for the cost. In a few states, carriers are forbidden from working around minor conditions in such a way, so they must make the decision to either accept or decline, in which case, they will always decline if the risk of costly treatment exists.

If you are going to say I'm wrong, then give me some examples to prove otherwise. I want to see details, and proof that appeals were filed if applicable, and what the division of insurance had to say about it, etc.

 

[Rich_by_the_Bay]

I think the point is being missed here.

Instead of niggling over whether acne is an excluded condition due to Accutane, isn't it inherently unacceptable that the system and laws which govern it put well-meaning people with prior illnesses in a position where they can't get complete health insurance, even when willing and able to pay for it?

Yes, if I were an insurance carrier CEO I'd do everything I could to cherry-pick and underwrite. The current system makes that necessary for corporate survival. It would be corporate suicide not to do so. That's the system. That's the problem.

Change the rules and enforce universal coverage, and let them duke it out on that playing field. Everyone gets coverage for acne. In fact, the carriers shouldn't even need access to your medical history when taking you on as a subscriber, and their competition is in the same boat. Level field, broad basic coverage.

 

[mykidslovedogs]

I agree that there should be broad BASIC coverage (catastrophic with preventive care included)....but what people who advocate universal care want is full coverage for pre-existing conditions, little or no out of pocket responsibility, and someone else to pay for it all. It's idealism that is not possible without serious trade-offs. You can't have it all. Private carriers, IMO, are going to be the most efficient at controlling costs through market forces, vs. counting on the goverment to control costs through price controls and care rationing.


The point I am trying to make here is that private carriers DO NOT decline people from coverage for minor illnesses, unless the risk of costly treatment exists or unless crazy state laws force carriers to choose to either accept or decline with no other alternatives such as exclusions or premiums ratings for particular conditions. Take away the stupid coverage mandates for minor conditions, and we could probably insure several million more people at a reasonable cost WITHOUT having to count on the goverment OR raise taxes.

I've gotten many people insured who have had pre-existing conditions, with satisfactory coverage at an affordable price. You just have to sometimes know what information to provide with the application. Too many people give up after trying to get covered on their own without a broker (because they try to place themselves with the cheapest carrier rather than trying to find one that will be a good match based on underwriting guidelines....or because they get pissed off at the insurance company and refuse to take the extra step to obtain their records and do what is necessary to get through underwriting, because they take the underwriting process too personally.

 

[FIRE'd@51]

I think the point many are trying to make is that even the application process has gotten too complicated - in fact, so complicated that even the insurance companies don't do a thorough check of past medical history during the underwriting process. So even if you are lucky enough to "qualify" for insurance, you still don't know if you really have it, since the insurance companies can "re-underwrite" after you file an expensive claim and possibly rescind your policy. Perhaps, their should be a 6-month period afterwhich the insurance company can no longer challenge the application. I believe something like this exists with life insurance policies.