Pre-Existing Condition is Any Visit to the Doctor?

November 3, 2009

I’ve come to the realization that universal health coverage is actually a good thing, if the whole point of health coverage is “just in case,” like auto insurance. And the people who tag “universal health coverage” as being “socialist” clearly have never applied for an individual health plan.

Currently, I have 2 options:

  1. Apply to as many individual plans as possible and hope that the law of averages tips in my favor and one of them will grant me coverage
  2. Apply for coverage under the Illinois Comprehensive Health Insurance Plan (CHIP)

I am perfectly OK with applying for as high-deductible a plan as I can find. I don’t really need coverage, as I’ve said before, but experience has taught me that it is good to have “just in case.” Call it a security blanket if you want. There is comfort in knowing that it is there, and a great deal of discomfort with the knowledge that, right now, it is not.

Both options require time, so I went online and filled out the “Online Application” for CHIP. The Illinois state government definition of “online application” means that you fill out a form which converts to a PDF that you then must print out, sign in ink (they specifically state ink) and then mail to the address provided with all supporting documentation. That supporting documentation must come from the former employer and/or insurance company to officially verify that:

  • Yes, I was laid off
  • Yes, I was covered under COBRA for 18 months
  • Yes, all options have been exhausted and other coverage denied or exhausted
  • No, coverage has not lapsed for more than 90 days

So I had to contact my former employer and now I have to wait, though not too long as an email from CHIP said “We received your application. Please mail the signed application, along with all supporting documents, no later than 21 days after submission.” And then I have to wait 2-4 weeks for the application to process, and there is no guarantee that I will be covered. Isn’t that nice? Apply for state coverage and the state may deny you as well.

When I called to inquire about the process and told them I had been on COBRA and received an individual plan rejection letter that included the CHIP phone number, they said I was a “high risk” applicant and should apply for coverage under the HIPPA CHIP plan since it has no “pre-existing” condition clause. I bit my tongue and hung up since, as far as I have been able to find on any number of “pre-existing” condition lists, I don’t have any.

So imagine my surprise when I read Step 11: Important Information on the CHIP application. It states:

A pre-existing condition is any condition for which medical advice, diagnosis, care or treatment was recommended or received within the six-month period immediately preceding the effective date. Medical treatment includes prescription drugs.

By that definition, a doctor’s visit for the common cold six months before the effective date means a pre-existing condition exists.

That is a considerably more expansive list than any list I have been able to find so far. Reminds me of “SiCKO” where a former health insurance employee said the “pre-existing condition list” was quite expansive, followed by the theme from Star-Wars as an alphabetized list appears like the opening of the Star-Wars back story.

Or am I missing something?


Individual Health Coverage Denied

November 1, 2009

Since being denied an individual health insurance plan from the SAME INSURANCE COMPANY I have used for the past 4 years, albeit under an employer plan (not to mention COBRA, twice), my view of insurance companies has changed.

I used to think they were a necessary evil that, in the end, were there when you needed it. That’s the point of insurance in this day and age, after all. You don’t need it until you do, and then you’re glad to have it. But you don’t need it until you do because the insurance companies make it so. That’s how they make money. They charge high premiums just in case you need something from them.

If you’ve followed me on Twitter, you know I’ve been absolutely livid since I was denied. And it took them a month and a half, a month and a half! to deny me coverage. This after the people who took my information, even read my claims back to me, didn’t see any “red flags” and said since I was a “returning customer” it shouldn’t be more than a couple of weeks. Clearly the company needs to revamp its application process so that “red flags” are used earlier, say during the application process, so the denial comes faster and the applicant, myself, can move on to other options BEFORE current coverage lapses. That obviously makes too much sense and would introduce efficiency into the system. Godforbid there be such a thing as efficiency in insurance.

Turns out health insurance companies find any possible reason to deny individual coverage, though the extent of the denial, or the underwriting process, varies widely by state. Illinois happens to be one of the worst offenders (the insurance companies run the show and thus wrote the laws. Really, in what other state does one health insurance company own 52% of the market?), and I just happen to think staying with one of the sloppiest insurance companies because they had treated me well before was a good idea. Apparently once you switch to an “individual plan,” your present a greater risk than if you are grouped with an “employer plan.” Your medical records get scrutinized, kind of, not by the health insurance company, but by its medical underwriters who may or may not be “in house.” They are looking for “pre-existing” conditions first, and then any hint of a problem, recurring or not. I have claims on file, from 4 and 5 years ago, and that was enough evidence that I have a “history” and thus am to be denied.

The definition of “medical history” is anything “out of the ordinary” that is in your medical file. It only has to happen once, and if it is “out of the ordinary,” you’re denied. And being denied automatically makes you a “high risk” applicant.

Now, if I had any “pre-existing” condition, or was taking any prescription medications at all, then the “high risk” tag probably would apply. I don’t have a “pre-existing” condition, at least not on any of the lists I’ve found, and I take no prescription medications. I don’t take any medications at all. By because I have been denied an individual health plan, I am automatically considered “high risk,” regardless of the lack of criteria for meeting “high risk.”

As irked as I am, I am struck by how ridiculous it seems to deny healthy people coverage, or to deny even reasonably people like myself, coverage. It shrinks the applicant pool, so less money is going in, which means those insured have to pay more so premiums continue to rise.

I would like to point out that I am fully capably of paying for insurance, and that I’d like health insurance just in case. I have been hit by a bus once, and walked away unscathed, but there is nothing that says I will be as fortunate in any other accident. But at least one health insurance company believes I am not worth insuring, and it would thus rather charge its current pool of applicants more to make up for the money it won’t get from me. And it’s not like I’m filing claims left and right. I prefer to stay healthy, get regular check ups and, well, stay healthy. There just used to be an added layer of security that in case of an accident, I was covered.

If this is how one health care insurance company treats “returning customers,” then I wonder what others have to say. And health care reform cannot come soon enough.

Since plans vary widely by state, it’s rather ridiculous how widely they vary, a universal plan is making more sense to me now. There would be an unified standard by which all applicants can be measured, and your premium would go up or down depending on where you fell in relating to that standard. As it stands, a person in Wisconsin who has had major surgeries and been hospitalized can receive individual health coverage while me, who has not had surgeries nor been hospitalized, cannot receive individual health coverage.

They system is clearly broken in ways people have yet to understand.

If the government runs the health care system, profits will not be the main motivation. I didn’t think it was so before, but having gone through this rather aggravating experience, I’m starting to believe a universal plan makes sense. But alas, this seems to be another one of those things you just don’t get unless you’ve experienced it. If it is anything like unemployment, than I am ahead of the pack again and this time next year, the masses will demand the heads of health care insurance companies just as they demanded the heads of Wall Street.

Hopefully the government will deliver better results than it has so far with Wall Street.

And this is more than likely not going to be the final post from me on health care. The more I dig into this issue, the greater the desire to educate people about it. Ignorance may be bliss, but it leads to a rude, maddening awakening.