I'm confused about pre-existing conditions. I cannot think of a better way to ask the question, but here goes. Replace diabetes with any at-birth disease/affliction you want (or really any adolescent onset disease/affliction).

If my wife and I have a child born with diabetes, my understanding is that treatment for said diabetes will be covered by our health insurance. At some point he/she will graduate from college and be kicked off our health insurance. Presuming he/she has a job with medical benefits, will that insurance accept diabetes as a pre-existing condition and cover the treatment?

(I'm asking about the pre-Obamacare world of insurance.)

In a job with benefits, almost all policies accept pre-existing policies. In a single/private policy, probably not.

The one complicating factor could be with policies that have lifetime caps on benefits. Not sure how that would work out, when you transition between plans (whether because the adult changes while the child is on the policy or when the child gets a policy). You probably really need to look at the policy language in that situation.

The trick is not to have a gap in coverage. If he/she is on your policy, without a gap, until the time he goes on another policy, he/she should be covered on any new policy without regard to preexisting condition (I know that is the law for group policies, not 100% certain about individual). That's why it is so important to keep COBRA if you lose a job.

(03-25-2010 02:02 PM)Hambone10 Wrote:  In a job with benefits, almost all policies accept pre-existing policies. In a single/private policy, probably not.

This is the case, except that if you have been without coverage for more than two months, the new employer-sponsored plan can exclude coverage for the pre-existing condition for up to 12 months. If you have had qualifying health coverage leading up to your new plan, they cannot exclude it (assuming you present the new plan with a letter of creditable coverage from the old plan... which the old plan is required to provide). That is current law following the passage of HIPAA in the '90s, but only applies to group coverage. (The P in HIPAA was for portability, though many people think it was for privacy).

Googling creditable coverage brings up what appears to be a good FAQ on the subject:
http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html

(03-25-2010 02:44 PM)Owl 69/70/75 Wrote:  The trick is not to have a gap in coverage. If he/she is on your policy, without a gap, until the time he goes on another policy, he/she should be covered on any new policy without regard to preexisting condition (I know that is the law for group policies, not 100% certain about individual).

Doesn't mean squat for individual. Not in Texas anyway. (As a side note, in Texas, most individual plans for women won't cover reproductive health in any way; it's basically like they treat being a woman of child-bearing age as its own pre-existing condition that is non-covered.)

Thanks, guys. FYI: no diabetic children and the 3 I have are very healthy. That's was just the best way I could think to phrase the question.

(03-25-2010 02:48 PM)texd Wrote:  

(03-25-2010 02:44 PM)Owl 69/70/75 Wrote:  The trick is not to have a gap in coverage. If he/she is on your policy, without a gap, until the time he goes on another policy, he/she should be covered on any new policy without regard to preexisting condition (I know that is the law for group policies, not 100% certain about individual).

Doesn't mean squat for individual. Not in Texas anyway. (As a side note, in Texas, most individual plans for women won't cover reproductive health in any way; it's basically like they treat being a woman of child-bearing age as its own pre-existing condition that is non-covered.)

Thanks for filling in that gap. I knew it worked for group, but have never dealt with individual policies so I wasn't sure.

Steven, a bigger issue in your hypothetical is what happened to me. Congenital heart valve defect (bicuspid valve instead of the usual 3 flap variety). NOT diagnosed despite years of annual physicals for atheltics, then various insurance policies. Valve fails, leading to an aortic dissection, several months in the hospital, a titanium valve and dacron tubing for an aorta and, ultimately, a bill for $500k+. Health insurance response? "Oh, that was a preexisting condition you didn't tell us about, so we are cancelling the policy retroactively to the time you bought it 14 years ago. But we are going to be magnanomous and not seek reimbursement for any bills we paid during those 14 years. Of course we are not going to reimburse you for premiums you paid either. And that $500k bill? It's for a pre-existing condition, so that claim is denied." Nevermind that I had a clean bill of health from THEIR chosen doctor during their required yearly physical just 3 days before the problem! Nevermind that the policy has a little word in it that they ignored: the exclusion was for KNOWN, preexisting conditions. I had to sue them to get them to honor the policy. The claims adjuster told me later that their standing, unwritten policy was that any bill over $200k automatically gets denied and coverage cancelled since their models show that less than 10% of people who get the denial of coverage sue them for it. When suit is filed, they pay before the answer date so the increased cost to them is negligible.

FWIW, I don't see anything in the ObamaCare bill that prohibits the insurance companies from continuing this practice - "we will cover your preexisting conditions if you tell us about them, but if you don't tell us, no coverage. Oh, you didn't know about it? You should have. Besides, you didn't tell us about it, so no coverage." As an aside, some hospitals have started getting wise to this and suing on behalf of their patients with large bills since they know that in many cases the patient can't afford to pay them and is unlikely to sue on their own behalf.

Query: does anybody know if the ObamaCare bill (and I am certainly NO expert on it) provides for issuance of policies with express exclusions of preexisting conditions? If so, that is not much different than the current situation - it just mandates issuance, presumably with a higher premium. and mandates that the public buy it whether they would choose to spend their money that way or not.

*OK, I'll get off my soapbox now. I still get P.O'd by this particular topic since I feel like the insurance company took the actions they did figuring the patient was disincliined to sue and probably not strong enough to handle the rigors of litigation after a prolonged hospital stay.

(03-25-2010 03:18 PM)RiceDoc Wrote:  FWIW, I don't see anything in the ObamaCare bill that prohibits the insurance companies from continuing this practice - "we will cover your preexisting conditions if you tell us about them, but if you don't tell us, no coverage. Oh, you didn't know about it? You should have. Besides, you didn't tell us about it, so no coverage." As an aside, some hospitals have started getting wise to this and suing on behalf of their patients with large bills since they know that in many cases the patient can't afford to pay them and is unlikely to sue on their own behalf.

Query: does anybody know if the ObamaCare bill (and I am certainly NO expert on it) provides for issuance of policies with express exclusions of preexisting conditions? If so, that is not much different than the current situation - it just mandates issuance, presumably with a higher premium. and mandates that the public buy it whether they would choose to spend their money that way or not.

The bill prohibits rescission, which sounds like exactly what they tried to do with you. Cases of fraud (and this was not even alleged as fraud) would be an exception.

No exclusions would be allowed for the plans, and everyone will be required to be covered by a plan. Plans are prohibited from differentiating premiums based on gender or health (e.g. pre-existing conditions). Premiums may vary ONLY based on age (3 to 1 total age variation ratio from top to bottom), geographic area, tobacco use (3 to 2 ratio max), and total number of family members to be covered by the policy.

Interesting premiums can vary by number of people covered in new legislation. That hits close to home (me, wife (stay-at-home mom with no other access to insurance) 3 kids and a fourth on the way). Our family is definitely larger than the average American family.
Of course, the composition of my family (pregnant wife, young kids) makes health care an incredible deal for me. A pregnancy alone is like 10x out-of-pocket what I pay in premiums. Hell, a trip to the pediatrician in a month basically cancels the premium.
I suppose it could be cheaper but I feel that way about just about everything...

texd, thanks for the clarification on that. As a practical matter, I will (I think) personally benefit from this passing because of the prohibition from differentiating premiums based on my now pre-existing condition (after they had to reinstate the policy, the premiums magically tripled). Despite that clear benefit to me personally, I don't think the country can affod this "fix" - my sense is that while my premiums may get cut in half, every else's will go up by half so that we have the same premiums.

*Another aside - the stated basis for the increased premium is a likelihood of heart valve related reoccurrence issues. If I had a pig valve, that would (again as I understand it) be supportable, but with a titanium valve with a "lifetime warranty", I would think I have LESS chance of a valve problem occuring again. Of course there are potential problems associated with the blood thinners I'm on now, but that is a different issue and not the justification that the insurance company used.

You're close Doc... but I fear the net premiums will actually increase significantly. While what they did to you is ahborrent and I wish they could be penalized for having policies like that... the fact is, they exclude people and procedures, and apply caps and co-pays in order to keep costs low for everyone else. When you take those things away, prices go up. This is, afterall, a business... and they will simply charge a higher rate to cover what they anticipate will be higher expenses. If just one person is expected to exceed the cap, the price will rise. If just one person is expected to be covered who was previously excluded... the price will rise.

An example was given in another thread... $900/mo premium for a family of 4... with limitations and exclusions... roughly 60mm families... now, an additional 5mm families who were previously denied coverage like you will be added to the rolls... assuming your example of a tripling in premium, we have 60mm x 900 + 5mm x 2700 = 67.5byn/65mm families = $1040 per family... more than a 10% increase. As you allude to, Yes, a decrease for you, but an increase for everyone else... and insurance comapny profits are around 2-6% depending on years... so even if we went 100% non-profit yet still actively tried to control costs, we'd have an increase.

THIS is why this thing just doesn't add up to me. Politicians will say, we're cutting premiums by as much as 63% for millions of families, which is true... and they can say we'll provide subsidies to millions of others to help them buy insurance... which is also true... (i believe the subsidy ends at 88,000 for a fam of 4) but that subsidy isn't likely to cover the price increase, much less actually reduce the cost... certainly not for any family making more than 88,000... and many who make much less than that are the ones who don't have any insurance at all. How are we cutting their cost from "zero"??

They've expanded coverage in theory, sure... I mean, EVERYONE was covered... just now they don't have to go to the emergency room to get treatment... but absolutely NOTHING has been done to address the TOTAL cost of that coverage.... We're merely shuffling the numbers around so we can make claims.

(03-25-2010 03:18 PM)RiceDoc Wrote:  Steven, a bigger issue in your hypothetical is what happened to me. Congenital heart valve defect (bicuspid valve instead of the usual 3 flap variety). NOT diagnosed despite years of annual physicals for atheltics, then various insurance policies. Valve fails, leading to an aortic dissection, several months in the hospital, a titanium valve and dacron tubing for an aorta and, ultimately, a bill for $500k+. Health insurance response? "Oh, that was a preexisting condition you didn't tell us about, so we are cancelling the policy retroactively to the time you bought it 14 years ago. But we are going to be magnanomous and not seek reimbursement for any bills we paid during those 14 years. Of course we are not going to reimburse you for premiums you paid either. And that $500k bill? It's for a pre-existing condition, so that claim is denied." Nevermind that I had a clean bill of health from THEIR chosen doctor during their required yearly physical just 3 days before the problem! Nevermind that the policy has a little word in it that they ignored: the exclusion was for KNOWN, preexisting conditions. I had to sue them to get them to honor the policy. The claims adjuster told me later that their standing, unwritten policy was that any bill over $200k automatically gets denied and coverage cancelled since their models show that less than 10% of people who get the denial of coverage sue them for it. When suit is filed, they pay before the answer date so the increased cost to them is negligible.

I have a genetic condition (mild) which increases my chance of an aortic dissection/aneurysm, so beyond having my sympathies for how you were treated by your insurance company, let me just say that I'm really really happy you survived... that is not a small problem (!!). And probably terrifying. Wow.

(03-25-2010 03:53 PM)RiceDoc Wrote:  texd, thanks for the clarification on that. As a practical matter, I will (I think) personally benefit from this passing because of the prohibition from differentiating premiums based on my now pre-existing condition (after they had to reinstate the policy, the premiums magically tripled). Despite that clear benefit to me personally, I don't think the country can affod this "fix" - my sense is that while my premiums may get cut in half, every else's will go up by half so that we have the same premiums.

*Another aside - the stated basis for the increased premium is a likelihood of heart valve related reoccurrence issues. If I had a pig valve, that would (again as I understand it) be supportable, but with a titanium valve with a "lifetime warranty", I would think I have LESS chance of a valve problem occuring again. Of course there are potential problems associated with the blood thinners I'm on now, but that is a different issue and not the justification that the insurance company used.

Wow, that's great to hear you're doing well. Ever since John Ritter died, I've assumed that aortic dissection was a death sentence.
Also, I feel a connection to congenital heart defects. My nephew was born with transposition of the great arteries (pulmonary artery and aorta were switched at the connection to the heart); fortunately they diagnosed it in utero and were prepared for open heart surgery when he was born. He's 17 months now and doing awesome.

And on your aside, I might have to defend* the insurance company on the higher premiums. Your old rates weren't based on reality, but on the assumption that you didn't have a congenital heart defect. So while the titanium valve is an improvement over what you had, I fear the technology is still such that the risks for someone with a titanium valve are a good bit higher than someone with a healthy heart. So I can see why your titanium-valve premiums are higher than your old (assumed) healthy-heart premiums.

*But I couldn't be more pissed that the insurance company forced you into the legal system just to provide you the coverage you had paid for. It's great that you didn't back down. But I'm sure it cost you money to fight them. And then the other 90% of the time that they get away with is simply robbing their customers (or more likely the doctors/hospitals who never collect the fees from the patient).

Appreciate the omments Emmie and Jowl,

Yes, an aortic dissection is what killed John Ritter. I had mine while I was driving on 249. I thought I was having a heart attack, so I grabbed my cell phone, called my wife and asked her to notify Tomball hospital that I was already on the freeway and about 2 minutes away. Next I looked for aspirin which I thought was in the center console of the truck, but didn't find it. By the time I arrived at the hospital the pain had subsided and I parked and walked in. They checked me out and said, "Good news and bad news. Good news is you are not having a heart attack. Bad news is that you are having an aortic dissection. Worse news is we can't deal with it, so you will have to go to Hermann Hospital." I said ok, just let them know I'd be there in about an hour. They responded, "You don't understand, you're not driving anywhere." I said, "Fine, which way to the ambulance." They said, "The ride in an ambulance would kill you. You get to take a helicopter ride. Now lie back down!" Now THAT got my attention!

By the way, the ER doctor has since told me that he has seen 1, sometimes 2 aortic dissections per year for the last 30 years and, counting mine, he has now seen 1 that was not post-mortem. Mine split the first of 3 concentric layers in the aorta and the valve tore completely way from the heart and was starting to tear the second layer as it worked its way downsteam.

And Emmie, I had a bicuspid heart vavle, which is considered to be a congential heart defect and apparently significantly raises the odds of having an aortic dissection. Apparently there are genetic markers for it, but I had never been tested and had no known family history of it.

Wow, that's a thrilling story, RiceDoc! And those are some long odds you overcame.

Driving yourself to the hospital while having a heart attack, then chopper to the big hospital. Would make for a cool episode of ER (or whatever doctor shows are actually on the air right now).

My seventeen year old daughter had a Glenn Shunt at one day old and the first half of a Fontan at one year and the second half called now the "Classic Fontan" when she was two. Basically she was born with no right ventricle and "No plumbing" to her lungs. Her first one, they connected her heart to her lungs with goretex, the second and third operations connected the inferior and superior vena cava to the lungs somehow. Prior to obamacare we have told her to begin thinking of a career with some govt entity so she could get on group insurance. Before TRS care was available to teachers, I did have to turn down a promotion with a school with private insurance. Didnt like it, but I did understand. Now teachers can move in and out of school districts and carry the pre existing with them. I carry her now on TRS retirement care which is not as good, I have the middle plan.
What scares me the most now is not whether she will be insured, but will those guys be around for her? She goes and will always go to a pediatric cardiologist, adult cardiologist dont even know supposedly. Will transplants if needed be off the plans now?
We will face that, I guess as we always have-- with a lot of faith. By the way, she is a cheerleader and can do all the flips that my $75 bucks a month has paid for all the years. She would be very happy teaching and has a gift with kids. She cant run a mile, but who wants to? We have been blessed, and I know there was a baby at Childrens who flew in on a lear jet and his parents did not pay a dime, my insurance paid a quarter of a million, so we probally paid for his. I think some of these things could have been addressed without a complete overhaul, and I worry about the Doctors you would see at six in the morning and at midnight, is it worth it for them?