Reader Stories

Denied Health Care Coverage? TELL QUEERTY

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Looking to buy a private insurance plan? Great! The Obama administration says it wants to make it affordable. But anyone in the market knows decent health insurance is often prohibitively expensive. Then there’s this extra hurdle: Say you should have a common ailment like Rheumatoid arthritis, or even acne, your application has a significant chance of being denied. Automatically. That’s because health providers don’t want to inherit your existing problems and their costs, so it makes better business sense to just say no. And what about more serious health issues, like diabetes, hepatitis C, multiple sclerosis, schizophrenia, quadriplegia, Parkinson’s disease, and a little something called AIDS/HIV? Yeah, good luck with taht.

With a big of investigative journalism nachas, the Miami Herald tries to get insurance companies to go on record with their underwriting policies — the fine print they go by when determining who gets coverage. Not surprisingly, most refused to make executives available for comment, nor provide copies of their “confidential” and “proprietary” policies.

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Insurers have different criteria. Sleep apnea and fainting for no known cause are reasons for denial for the Nebraska plan, but not for other plans. Vista doesn’t want to cover severe acne, but other guides seen don’t mention it. Insurers often use measures of body mass index to reject those who are too heavy or too thin.

For cancer, the key is how patients have been doing in remission. Wellpoint, a national insurer, rejects applicants who have had breast or prostate cancer within the past five years. With other types of cancer, 10 years must have passed. Assurant Health, based in Milwaukee, rejects most patients whose cancer has not been in remission for at least eight years.

Other reasons for automatic denial by various companies: alcohol-related problems of people who have not been abstinent for at least six years, chronic bronchitis, severe migraines, and a cardiac pacemaker installed within the last two years.

Some insurers will automatically reject applicants who are using certain prescription drugs. Wellpoint denies anyone who within the past year has taken Abilify and Zyprexa for mental disorders as well as Neupogen, which is used to treat the side effects of chemotherapy. Vista lists the anticoagulant Warfarin and the pain medication Oxycontin. Both companies list insulin.

And what if you lie on your insurance application, and accidentally forget to list a certain medication or problem you’ve got? Providers have a tendency to find out anyhow, and deny you coverage, thanks to the data mining firms they hire that keep tabs on every time you fill a Rx.

To make sure that applicants are not lying, insurers hire a data-gathering service — Medical Information Bureau, Milliman’s Intelliscript or Ingenix Medpoint.

Intelliscript and Medpoint do computerized searches of a person’s drug use, gleaned from pharmacy benefits managers and other databases. The two companies say they comply with privacy laws. ”Ingenix requires each Medpoint client to obtain the authorization of the individual applicant or insured person,” said Ingenix spokeswoman Karin Olson.

YOU TELL US: We want to hear your experience with health care coverage. Are you covered through work? Through your own private policy? Or are you without health coverage at all? Have you run into problems trying to get a policy because of a certain health problem? If you’re willing to share your experience with readers, please include as much of the following as possible (feel free to copy/paste this list into your comment and fill in the blanks):

1) Age & Gender:
2) The state I live in:
3) I have health coverage through: work, Medicaid/Medicare, private policy, other (i.e. parents), or none (Please name the insurance carrier)
4) Each month I pay: $
5) In brief, my policy covers:
6) Have I been denied coverage before? If yes, here’s why:
7) My best story about dealing with my insurance company:

I’ll start.

1) Age & Gender: 25, male
2) The state I live in: California
3) I have health coverage through: Private policy, Anthem Blue Cross
4) Each month I pay: $200
5) In brief, my policy covers: Standard policy. Doctor visits with $10 co-pay. Emergency room. Deductible of 20/80 with ~$1,000 annual cap (i.e. I pay the first 20 percent of all fees every time I need care, up to an annual ceiling of $1,000). Prescription drug coverage (~$5 per prescription).
6) Have I been denied coverage before? If yes, here’s why: No, fortunately
7) My best story about dealing with my insurance company: I’ve been pretty lucky, all things considered. Biggest headache was paperwork, dealing with an ER visit when I sliced open my finger. I didn’t have my insurance card on me at the time, so getting my insurance company to reimburse me after the visit was a 10-phone-call process. I’m well aware this is barely a gripe when it comes to others’ more disturbing stories.