No health care for you! Come back one year...

[M Paquette]

I got the results back on my application for a family high deductible/HSA plan today.

Mine: The dog ate it?

They found it.

Rejected: A benign polyp was found and removed on my last colonoscopy.

 

[ERD50]

.... i'm left wondering what is it about the American system of health care thats better than the Canadian system?

Just a guess here, but I wonder if maybe the Canadians trust their officials to do a better job managing nationalized health care than US citizens trust our Congress?

IIRC (this might have been from soapbox days), the Canadian campaign season is much shorter than ours ( focus on issues) and there is actually a significant 3rd and 4th party representation?

I am (theoretically) in favor of more govt involvement in our health care system, but I'm afraid that whatever Congress comes up with will be even worse than the mess we have now. These are the same people who decide that junking a working automobile and replacing it with a new one with marginally better mpg is a good use of $3,500-$4,500 of taxpayer money. That does not appear to be based on any financial or environmental analysis, so I don't expect health care decisions to be made on analysis either - just whatever "sounds good" to whatever voting block they think they need help with that day.

-ERD50

 

[Bestwifeever]

That's terrible, Paquette--so you would have been better off insurance-wise to not have gotten a colonoscopy that resulted in a most minor problem being corrected. Shame on you for following health guidelines!

 

[samclem]

I'm intrigued by the Obama concept of a basic national insurance program for anyone who wants it, but allowing the private carries to offer either replacement policies or wrap-around policies. That plus universal access and no underwriting might be a good start.

But, can the US health care system provide the same quality of care as it does today if we change to a system where everything is reimbursed at the Medicare rate?
If there's a "public option," it will not be competing on an even playing field with private insurers. The "public option" will be subsidized by significant taxpayer inflows. The only way the taxpayer who has private insurance can recoup the taxes he's paying for the "public option" is to dump his private policy and jump into the public boat. The taxpayer subsidy will assure the (overt) premiums will be cheaper and individuals will convert to it. We already know how this public option works--we see it in Medicaid and Medicare. I don't think we'll see the present quality of facilities, professionals, availability of care, and quality of medical research when everything is being paid at the 83% of true value level we get with Medicare AND when there's no more honey-pot of privately-insured clients from which to make up the difference.

Does anyone think the "public option" is anything other than a means to eliminate private insurance from the marketplace?

 

[CuppaJoe]

They found it.

Rejected: A benign polyp was found and removed on my last colonoscopy.

Do they have any appeal process? I was turned down for my last application 16 years ago, and I wrote to them saying that the problem happened only once when I was a teenager and never recurred. They then approved my application.

This is really unconscionable considering you worked for a great megacorp. Maybe somehow they could help you out, it would be good PR.

I'm so sorry to hear about this, MP.

 

[lets-retire]

As one who is against the national health care I think i can give an insight as to why many Americans don't want it. We fought for our independence from a government. When we set up our initial government we had a very weak central government found that didn't work to well and developed a slightly stronger one that has remained for over 200 years. In that time the prevailing attitude of the American population has been to "do it themselves." It has only been the last few decades where the government has stepped in and started to really take a large part in our lives. It has been a slow creep, and I think many American still are of the mind set of "let me do it myself." I think Americans are becoming more scared about how things are done. This has caused the government to slowly provide more to the constituents. The European model came from the government providing for the people. The land was owned by a king who gave it to his favorite people to work so the king could have more. The Americans revolted against that ideology and wanted the government serve the people. Remember, "The government is of the people, for the people, by the people." I think that is still one of the underlying beliefs of the American population.

Personally I see it as a power grab. I don't see the cost of health care coming down. We subsidize the government systems of many countries by the cost shifting to the free market. I see a large influx of patients. I see a large retirement of doctors. All of this is without the government providing anything. With the government providing, I see a larger influx of people. No matter what the cost of medical care is going to go up. To think it will go down is ignoring the basic laws of supply and demand. I think the offering of a government health insurance policy is just the first step in the eventual take over of the health care system, especially with the ideas I seen floating around in DC. I've been a patient of the government health care system and still suffer from improper diagnosis of several issues. I had several other issues corrected by private doctors. I can honestly say the government provided health care I received was the worst of any I've had; even if I had to argue with the private doctors to provide or not provide the care needed.

 

[M Paquette]

That's terrible, Paquette--so you would have been better off insurance-wise to not have gotten a colonoscopy that resulted in a most minor problem being corrected. Shame on you for following health guidelines!

Too right. DD refuses to go see a doctor, and hasn't been in years. No problems, fortunately. (I know, bad Dad! Bad!)

Naturally, SHE was approved.

This pretty much convinced me that the system is set up to find reasons to deny coverage, rather than find appropriate coverage. An empty medical history has nothing that can be used to deny coverage.

 

[M Paquette]

Do they have any appeal process? I was turned down for my last application 16 years ago, and I wrote to them saying that the problem happened only once when I was a teenager and never recurred. They then approved my application.

This is really unconscionable considering you worked for a great megacorp. Maybe somehow they could help you out, it would be good PR.

I'm so sorry to hear about this, MP.

The appeal process is interesting. I can provide information to correct my own errors on the application, but for anything requiring medical opinions or judgement calls, they want a doctor to write it up on letterhead.

Now, I'm trying to get this coverage from a HMO I've been in for years. Guess what their doctors don't do? Yup. No explanations on letterhead. The reason given is that the underwriter doing the review has full access to the system's electronic health records. (eep!)

That'll put a chill in any discussions with the doctor.

Anyway, the application for individual/family coverage with a high deductible and HSA was just one branch in a decision tree. I've got lots of options left.

In this case, DD now has the HSA plan, so her rates drop. DW and I continue on COBRA on into 2011, and can try again for a HSA plan, falling back to 'conversion' to a HIPAA plan with no medical review (a bit more than COBRA, but with DD on the HSA, we are still in budget).

I thought the whole 'Denied!' thing was sufficiently interesting that posting it and chatting a bit might be of value.

By the way, I was curious as to what sort of medical background a medical underwriter would have if they were to interpret clinical notes correctly. Here's an actual job rec for a senior underwriter for individual/small group coverage.

http://kp.taleo.net/careersection/external/jobdetail.ftl?lang=en&job=001388

Sr. Individual / Small Group Underwriter(Job Number: 001388)


No matter what your job title, the work you do at Kaiser Permanente Georgia supports the health and well being of our Atlanta-area members. That’s because each of us—from our financial professionals and IT team members to our RNs and physicians on the front line of care—shares a commitment to providing the best possible care experience. Come build a rewarding career in an environment that supports your success. Join us and put your beliefs into practice.


Description

Underwriting's overarching function is to anticipate key business, marketplace and competitor dynamics in developing and implementing strategies to optimize business results which include retention and growth targets while mitigating risk. The position's primary focus is on establishing the appropriate rate and conditions of offering to achieve revenue, membership and margin goals. Additionally, processes and policies are managed to support optimal customer service while collaborating with Sales/Account Management partners to optimize business opportunities and effective solutions.

Essential Functions:
• Partner with Sales and Account Management to create and execute a business plan that optimizes our opportunities
• Produce accurate quotes in compliance with Underwriting & authority guidelines and state & federal laws for existing and/or prospective business
• Develop and execute business plans to ensure attainment of goals
• Conduct peer reviews
• Manage business processes and policies that support optimal customer service
• Meets established department turn around goals by balancing deadlines
• Recommend and implement new and existing policies, procedures, and methodology
• Recommend and implement continuous quality improvement programs
• Consult with internal customers on implications of decisions on business outcomes
• Ensure Underwriting is an integral partner in the creation of effective business solutions
• Establish relationships with Sales/Account Management that optimizes business potential with purchasers, brokers & consultants
• Develop creative solutions that increase credibility with customers & Sales/Account Management
• Acquire & exhibit knowledge of the external business environment to add value
• Provide leadership to Team
• Create and maintain positive, empowering work environment
• Act as a role model
• Coach and develop team members
• Develop and execute a plan for personal & professional development
Qualifications

Basic Qualifications:
• Bachelor's degree required or equivalent experience in mathematics, business administration, or a related field or applicable related work experience such as nursing training

Preferred Qualifications:
• Four+ years progressive medical underwriting experience in the health insurance industry and professional development
• Knowledge of small group health insurance legislation and regulations

Note the medical education requirements, and the clinical background? Neither did I.

 

[youbet]

Can we all agree that whatever healthcare system we wind up with:

1. Most people will need to pay more in premiums (or supporting taxes) than they consume in health care for the system to work. It takes a lot of premiums (or supporting taxes) from healthy folks to make up for one person needing lots of ongoing care.

2. The aggregate funding will need to equal the aggregate cost.

I get the idea from these discussions on the board that many are expecting that we'll all be saving big bux from whatever future healthcare plan comes rolling out of Washington. I don't think so. I still see it as "insurance" and most people will pay in more than they consume to provide funds for those who need to consume a lot.

 

[ERD50]

Too right. DD refuses to go see a doctor, and hasn't been in years. No problems, fortunately. (I know, bad Dad! Bad!)

Naturally, SHE was approved.

This pretty much convinced me that the system is set up to find reasons to deny coverage, rather than find appropriate coverage. An empty medical history has nothing that can be used to deny coverage.

I totally sympathize with the situation you are in, but it actually does make some sense from the ins co side.

What the ins co has to protect against, is the person finding out they are sick and then saying "Hey, I better get some insurance, now that I'm going to have some bills that need to be paid - I didn't need it when I was well". So to some degree, if a person has no recent medical history, the ins co might be able to assume that on average, that person is no higher risk than average. But if someone had tests performed, and it indicated even a chance for future problems, the ins co might see that as a sign of above average risk.

I'm sure that analysis is (very) far from perfect, but I think it does explain their approach. If the govt requires everyone to get coverage, there is no longer any need for ins cos to assess individual risk. It is all one pool. From what I understand, it seems unlikely that the govt will take this step. I doubt that anything less will be meaningful.

-ERD50

 

[ERD50]

Can we all agree that whatever healthcare system we wind up with:

1. Most people will need to pay more in premiums (or supporting taxes) than they consume in health care for the system to work. It takes a lot of premiums (or supporting taxes) from healthy folks to make up for one person needing lots of ongoing care.

2. The aggregate funding will need to equal the aggregate cost.

I get the idea from these discussions on the board that many are expecting that we'll all be saving big bux from whatever future healthcare plan comes rolling out of Washington. I don't think so. I still see it as "insurance" and most people will pay in more than they consume to provide funds for those who need to consume a lot.

I agree, but I do think it misses one pile of cash flow - the uninsured group that is supported by taxes or increased charges, expensive ER visits and maybe avoid some cost-effective preventive care.

I have no idea if that number is big enough to make a dent in the total, but I have little faith that our govt will be able to leverage it to a net positive anyhow.

-ERD50

 

[John Galt III]

That's terrible, Paquette--so you would have been better off insurance-wise to not have gotten a colonoscopy that resulted in a most minor problem being corrected. Shame on you for following health guidelines!

Exactly, BWE ! I currently have health ins thru my employer, but want to retire with hdhp sometime. Since I want to be accepted into the hdhp eventually, I make a point of NEVER telling my doctor of any health concerns I have, since they would of course be reasons for any hdhp to deny me coverage. Of course I would tell him of a life-threatening problem, but not about anything less serious. ( Example : I get heart palpitations and some chest pain once in a while, but I choose not to tell this to my doctor, for the above reasons. Also, I have visual distortions now and then, ala migraine halos, but will not tell my dr about them).

If and when I do get hdhp coverage, it appears it will be a "use it once then lose it" affair, in which they cancel my policy if I ever make significant use of it.

I remember reading some threads here before, about folks who did have good hdhp coverage, and were happy with it. Where are they now? Is it all gloom and doom?

 

[Martha]

JGIII, for goodness sakes tell you doc about these concerns. If they are not a problem then they are not a problem. If they are, they should be taken care of. Chest pain and palpitations are not hang nails.


BTW, under federal law a health insurance company cannot cancel you for making claims. They can discontinue policies and in a few states can raise rates.

 

[CuppaJoe]

.... I make a point of NEVER telling my doctor of any health concerns I have, since they would of course be reasons for any hdhp to deny me coverage. .... I get heart palpitations and some chest pain once in a while, but I choose not to tell this to my doctor....

What Martha said, and you might look into whether coverage is denied to dead folks.

 

[W2R]

BTW, under federal law an insurance company cannot cancel you for making claims. They can discontinue policies and in a few states can raise rates.

I really trust your knowledge of federal law because I know that you know what you are talking about. But somehow insurance companies have managed to get around it in Louisiana, at least when it comes to homeowners' insurance. Maybe you just meant medical insurance since that is what we are talking about here! But anyway, if we make more than 3 claims in a five year period (even small claims), our homeowners' insurance can and will be cancelled ("dropped"). Insurance here is regulated by our state insurance commisioner and so there is probably some technicality that allows them to do that.

I agree that anything related to heart health should be reported! It might turn out to be nothing, but if you can't get a doctor's opinion on it then we might as well be living in the jungles of a third world country. There's no sense in even having health insurance if you can't get health care.

 

[M Paquette]

What Martha said, and you might look into whether coverage is denied to dead folks.

Well, apparently someone can be 12 years dead and still covered by an Accidental Death and Dismemberment Policy.

In reviewing accounts for my mother's estate, I discovered that my poor mom had been leaking $4.00 a month from her checking account as an automatic debit for accidental death and dismemberment insurance on may dad, who had passed away 12 years ago. The bank and insurance company tried to blow it off, blaming each other. The bank put a 'stop payment' on the debit, but it mysteriously didn't work. (The insurance unit is part of the bank, but they don't want to admit it. Their stops won't block internal transfers.) Soooo... Now the bank and insurer are facing a fresh complaint via the Office of the Comptroller of the Currency. (The goal isn't to recover anything. I'll be closing the account in a few weeks. The goal is just to cost the bank/insurer more in expenses dealing with OCC than they took from Mom over the last 12 years.)

If the insurance company keeps making noises about how only my deceased father can cancel the policy, I might be tempted to have him disinterred. I'm sure something must have fallen off by now.

I've also gotten a couple of offers for 'No exam needed! Anyone qualifies!' medical insurance plans for Mom. (These have really funky exceptions and limitations that make them essentially useless.) Nothing in the application requires the applicant to be living, though...

Yes, I understand that an attempt to collect would almost certainly be insurance fraud. It's pretty silly, though.

 

[Martha]

I really trust your knowledge of federal law because I know that you know what you are talking about. But somehow insurance companies have managed to get around it in Louisiana, at least when it comes to homeowners' insurance. Maybe you just meant medical insurance since that is what we are talking about here! But anyway, if we make more than 3 claims in a five year period (even small claims), our homeowners' insurance can and will be cancelled ("dropped"). Insurance here is regulated by our state insurance commisioner and so there is probably some technicality that allows them to do that.

I agree that anything related to heart health should be reported! It might turn out to be nothing, but if you can't get a doctor's opinion on it then we might as well be living in the jungles of a third world country. There's no sense in even having health insurance if you can't get health care.

In most states (if not all) homeowners and car insurance is different. They can (and do) cancel you for your claims history. I clarified my prior post to indicate that the law only applies to health insurance.

 

[lets-retire]

I've heard of the cancelling, but typically what I've heard when the story is told is a refusal to renew not a drop.

 

[Martha]

I've heard of the cancelling, but typically what I've heard when the story is told is a refusal to renew not a drop.

Health insurance companies can't refuse to renew either based on your health condition. This is under HIPAA. However, they can raise the price, though in most states they can only do it for everyone who has that policy, though usually age related differences in price are fine. They can also eliminate the particular product, which they might do if the people who buy the policy are in such crummy health that it doesn't pay to keep it.

 

[John Galt III]

JGIII, for goodness sakes tell you doc about these concerns. If they are not a problem then they are not a problem. If they are, they should be taken care of. Chest pain and palpitations are not hang nails.


BTW, under federal law a health insurance company cannot cancel you for making claims. They can discontinue policies and in a few states can raise rates.

But here's the likely scenario. I'm 55. When I retire, sometime prior to age 66, if I choose to get private health ins, I'll have to get a NEW health insurance policy, not keep the old one I had through work. I won't be allowed to keep the old one. New prospective insurance co will deny me for even mentioning heart palpitations to my PCP, even if he says "you're fine. Go home". I'm assuming, perhaps wrongly, that my mentioning of heart palpitations to the dr will get recorded by him, and that the new prospective ins co will ask the dr for his medical records about me, and that the dr will provide all the info he has on me, to them.

In fact, I may already be out of the game, since I got treatment at a Phys Therapy place for frozen shoulder a year ago. If they don't care about anything that happenned over a year ago, I may have hope.

 

[Martha]

I understand JGII, but some things are too important to let go because of a possible future denial when trying to purchase insurance. If you are turned down for private insurance there will be a HIPAA option for you, though it might be pricey depending on where you live.

 

[Rich_by_the_Bay]

Yeah, we get it about your insurance situation.

It's your undiagnosed chest pain she's talking about. If it's a false alarm, your records will reflect that and likely not affect underwriting. If it's something that needs to be taken care of you will do so and live.

It's a bad system to be sure, but "suicide by denial" may not be the best approach...

 

[REWahoo]

JG3, your thinking sounds similiar to that of DD#2's father-in-law. He was self employed and kept putting off going to his doctor with some concerning symptoms because his insurance coverage wasn't very good and he was waiting until he got on Medicare. Everyone tried to tell him he shouldn't wait but he wouldn't listen.

Turns out he had prostate cancer which had already spread to his liver and his bones by the time he saw a doctor. He died within a few months of his diagnosis - but Medicare paid for 80% of his costs.

 

[John Galt III]

Thanks for the concern, everyone. I will mention the chest pain at my soon-to-occur annual physical. By the way, I did already mention the palpitations ( not pain) to my former PCP, about 8 years ago, and he didn't even have any tests ordered, although he said he would order tests if I wanted them. I declined. The pains are very rare, once every 2 months or so, and the palpitations occur only every month or so. May be my imagination, but I think the palpitations kick in whenever I remember to take my fish oil capsules, and after I have taken them several days in a row.
I understand the "don't gamble with your health" advice. Thanks.

 

[unclemick]

I really trust your knowledge of federal law because I know that you know what you are talking about. But somehow insurance companies have managed to get around it in Louisiana, at least when it comes to homeowners' insurance. Maybe you just meant medical insurance since that is what we are talking about here! But anyway, if we make more than 3 claims in a five year period (even small claims), our homeowners' insurance can and will be cancelled ("dropped"). Insurance here is regulated by our state insurance commisioner and so there is probably some technicality that allows them to do that.

I agree that anything related to heart health should be reported! It might turn out to be nothing, but if you can't get a doctor's opinion on it then we might as well be living in the jungles of a third world country. There's no sense in even having health insurance if you can't get health care.

Is the insurance commisioner in jail or out of jail nowadays? Back pre-Katrina I filed a complaint with them over my Homeowner's canceled policy and inability to get another one.

When I called up to ask(after a suitable waiting period) about my complaint - the nice lady said they couldn't do nothing - the commish was off to jail to serve his 6 month? term. I asked (being somewhat ticked) were they gonna keep getting their paychecks while the boss was in the slammer.

Yep.

heh heh heh - Got a great tax write off and Roth conversion when Katrina hit. Have a Passport but I'm not sure medical tourism can beat my Medicare/supplimental as an old phart.