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.
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):
How about we take this to the next level?
Our newsletter is like a refreshing cocktail (or mocktail) of LGBTQ+ entertainment and pop culture, served up with a side of eye-candy.
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.
larryh59
1) Age & Gender: 49
2) The state I live in: Texas
3) I have health coverage through: work, Medicaid/Medicare, private policy, other (i.e. parents), or none (Please name the insurance carrier) None
4) Each month I pay: $0
5) In brief, my policy covers: N/A
6) Have I been denied coverage before? If yes, here’s why:
7) My best story about dealing with my insurance company: Up until late 2007 I was working for a large corporation with decent medical coverage. That is, until a major incident involving hospital stay/surgery. The out of pocket costs add up fast, and before you know it you’re several thousand dollars in debt. Plus, the pay for service then get reimbursed later program is a joke. Now fast forward to today. I’m working for a small private business making much less money therefore can’t afford health insurance. That’s a whole other story. Just had the experience of trying to find medical assistance. What I can find involves higher co-pays than when I had insurance for one. That doesn’t even involve the paperwork/red tape to try and get any assistance. I don’t even want to think what would happen if I had a serious illness.
Kye
Maybe you’ve seen this:
http://www.californiaprogressreport.com/2009/03/alarming_incide.html
The author writes about his experience on the individual market.
suzygoo
1-43 male
2-Canada (previously in Arizona)
3-Primary health coverage through the Province, secondary health coverage through the federal government, private coverage through green shield, a private insurer for non-covered items and lastly reimbursement of any non-covered expenses through my employer.
4-I pay $150 a month for the private coverage of dental, eyeglasses and prescriptions.
5-My policies cover everything, including eye laser, dental implants. private hospital rooms, prescriptions.
6-No-against the law
7-only story is dealing with auditors who want to catch doctors double billling for the same procedure.
suzygoo
Oh, by the way, that $150 per month is for family coverage which my same sex spouse is also covered for everything plus any children we may have (but don’t). Only thing it does not cover is bills for the pets.
rcdc
1- 22 F
2- DC
3 – private, Carefirst BCBS
4 – $71
5 – standard, no vision no dental, high deductible HSA plan, moderate prescription coverage.
6 – yes, bipolar disorder. fortunately, my “technical” diagnosis, and everything that was ever filed with my parent’s insurance, has my diagnosis as dysthymia, which, unlike the riskier bipolar disorder, is not an automatic rejection.
7 – i’ve only had the plan for two months, and can still get basic care free through my university, so… only thing i’ve noticed is that they’ll only cover a month of meds at a time, no matter what kind of medication it is
Carsen Tyler
1) Age & Gender:19, Female
2) The state I live in: California
3) I have health coverage through: work, Medicaid/Medicare, private policy, other (i.e. parents), or none (Please name the insurance carrier): Parents( Healthnet-Brown and Toland), School( Blue Cross)
4) Each month I pay: Not sure what my parents pay. But I cover all my co-pays, and I pay $100 on a good month where I just need my meds and med-management. But If I have to see my doctor and other specialists it can go up to $600. Most of the money I make goes to my medical bills.
5) In brief, my policy covers:$25 copay for doctor visits, Meds copays $10 to $50 (I am on 6 medications), Behavior Health $25 copay for regular psychiatrist and med management, $30 copay for family therapy and training. My parents cover the costs for vision and dental. I am not sure yet on how much the physical and occupational therapy is going to cost me. But the Adapted Drivers therapy is going to cost me $500 for the evaluation and first 3 hours of instruction.
6) Have I been denied coverage before? If yes, here’s why: I am turning 20 this year and my parents insurance wants to drop me. They have denied all of the paper work that I have turned saying I am a full time student but they can’t deny the most recent paper work I gave them. My primary care physician is angry about that. I have Tourette’s Syndrome, Schizoaffective Bipolar disorder, Complex Migraines, an undiagnosed muscle disorder, and UCSF prefers to treat me with specific specialists. Insurance doesn’t want to pay for 2 psychiatrists or a specialists that they don’t have in network. This is the third time I have come under risks of not having insurance. Every time my birthday approaches they try to drop me.
7) My best story about dealing with my insurance company: Not many decent times with my insurance. But it is better then when I had a different provider. It doesn’t become screaming matches any more.
Bob R
1) Age 60, will be 61 in a matter of hours. Male.
2) State: Ohio (rural Appalachia)last 3 years, previously Florida 30+ years.
3) Currently covered through VA for disability (Agent Orange exposure), also have Medicare A&B with a supplemental plan. Used to be insured through my employer, but each year the plan benefits decreased and co-pays, deductibles increased. A lot.
4) Currently I get all my medications free, mailed to my home via the VA. I see doctors at the VA (routinely every 2-3 months or as needed)and specialists through Medicare because I live in a very rural area and to see a VA specialist would involve an 80 mile one way drive. To see a cardiologist (specialist) locally through Medicare I have a $35 co-pay. Medications prescribed through my Medicare specialist I either get through my Medicare drug plan or the VA.
5) Could I get insurance on my own? No, not anywhere at any price. I have chronic heart failure, had by-pass surgery, asthma and I’m Diabetic.
6) Have I been denied coverage? Yes. I cannot even get life insurance.
7) I’m very happy with my local VA clinic and doctors. I have no trouble getting appointments, they are very attentive and willing to spend time with me. Labs and tests cost me nothing, that includes radiology, etc. The VA doctors encouraged me and assisted me in applying for and obtaining VA disability and Social Security Disability. I’m (so far) happy with Medicare, although the drug plan can be a little pricey with all the tiered co-pays and that gaping “donut hole”. I like the VA, free is always better. However, because of my income from SSDI, next year my VA coverage may also involve co-pays for medications and perhaps doctor visits, but they should be less than under Medicare. I went over a year without any health insurance coverage until a fellow veteran referred me to the VA. I am totally in favor of a universal, single payer plan similar to the VA, Medicare or what is offered to our Canadian neighbors. Insurance companies, by far and large suck. I feel very lucky to have the coverage I have and have no complaints.
scott
whoa. u guys have some cheap insurance it seems. Well some of you do.
1) Age & Gender: 39
2) The state I live in: NYC
3) I have health coverage through: private policy via FreelancersUnion(dot org)
4) Each month I pay: $320
5) In brief, my policy covers: haven’t tested it out yet, but it covers most everything I think. Altho I have a high copay and high deductible and I’m screwed if I need to get lots of tests because of the high co-insurance
6) Have I been denied coverage before? If yes, here’s why: no.
7) My best story about dealing with my insurance company: no story yet.
Huh
1) Age & Gender: 42, Male
2) The state I live in: Missouri
3) I have health coverage through: work – Aetna
4) Each month I pay: $0
5) In brief, my policy covers: $15 co-pay – it pays pretty much everything else. Medications – covers most at big discount – but I pay about $100 a month for hiv medications – $50 for one, $25 for two others.
6) Have I been denied coverage before? If yes, here’s why: When I was first diagnosed with hiv, BCBS tried to claim it was a “pre-existing” condition because I had only had the coverage for 6 months. However, they dropped that objection pretty quick when my doctor intervened.
7) My best story about dealing with my insurance company: I have been pretty lucky. I was paying quite a bit with private coverage, but got a new job with great benefits and the insurance past and present has been very quick and convenient. However, I’ve never had major issues or been hospitalized – so others probably have more complicated situations.
elf
i have ben denied health insurance because of a false
diagnosis 9 yrs ago. i don’t know how to get it off my record.
i don’t have that disease, haven’t seen that dr in 9 yrs.
also because of a legal driving issue. ( i should of questioned that).
i don’t have any major health issues never been hospitalized.
these insurance companies come with so may ways to deny you, and ways not to pay claims.
i am going to try to get a county plan , i don’t know where else
to apply for insurance.
insurance needs to pay for morw preventive care. i never could meet my deductable when i had insurance.