Health Insurer Rules Unveiled - Acne, Pregnancy Among Disqualifying Conditions/Medical bills caught in former employer's plight

Health Insurer Rules Unveiled - Acne, Pregnancy Among Disqualifying Conditions
By David S. Hilzenrath
Copyright by The Washington Post
Saturday, September 19, 2009
http://www.washingtonpost.com/wp-dyn/content/article/2009/09/18/AR2009091803501.html?hpid=topnews


A proposal to make preexisting health conditions irrelevant in the sale of insurance policies could help not just the seriously ill but also people who might consider themselves healthy, documents released Friday by a California-based advocacy group illustrate.

Health insurers have issued guidelines saying they could deny coverage to people suffering from such conditions as acne, hemorrhoids and bunions.

One big insurer refused to issue individual policies to police officers and firefighters, along with people in other hazardous occupations.

Some treated pregnancy or the intention to adopt as a reason for rejection.

As Congress and President Obama work on legislation to overhaul the nation's health-care system, one of their main objectives is to stop insurers from denying coverage on the basis of health status. Proposed legislation would prohibit insurers from denying coverage to individuals with preexisting conditions or charging them higher premiums because of their medical history -- practices known as medical underwriting.

Even the insurance lobby has endorsed that goal as part of a larger reform package in which the government would extend coverage to the uninsured, greatly expanding the market for insurance.

Guidelines that insurance companies have written for professionals involved in selling policies offer a glimpse inside the underwriting process.

"What these documents show is the lengths to which insurance companies are willing to go to make a profit," said Jerry Flanagan, health-care policy director of the advocacy group Consumer Watchdog, which distributed the documents Friday. "What it shows is that insurance companies want premiums without any risk."

Consumer Watchdog argues that consumers should be given the option of enrolling in a government-run health plan. It obtained the documents from a California insurance broker, Flanagan said.

A PacifiCare "Medical Underwriting Guidelines" document from 2003 lists under "Ineligible Occupations" such risk-takers as stunt people, test pilots and circus workers -- along with police officers, firefighters and migrant workers.

Uninsurable conditions included pregnancy, and being an "expectant father" was grounds for "automatic rejection." So was having received "therapy/counseling" within six months of the application. There was also this more general disqualifier: "currently experiencing/experienced within the last 12 months symptoms for which a physician has not been consulted."

The PacifiCare document "is completely outdated and predates the acquisition of PacifiCare by United Healthcare," Cheryl J. Randolph, a spokeswoman for the parent company, said by e-mail. She declined to provide current underwriting documents.

"Underwriting enables insurers to adequately assess risks, keeping premium costs lower for more consumers," she added.

Health Net guidelines for 2006 say that people could be denied coverage or charged higher premiums if they were taking certain medications, including Zyrtec, an allergy remedy, and Lamisil, which is widely advertised as a treatment for toenail fungus.

Pregnant women could be rejected, as could expectant fathers, the document said.

A Health Net spokeswoman did not respond to requests to comment.

Blue Cross of California guidelines for 2004 said potential disqualifiers included chronic tonsillitis and, under certain circumstances, varicose veins.

Kristin E. Binns, a spokeswoman for parent company WellPoint, said by e-mail that she could not comment on the guidelines because they are from years ago.


What's your Problem? By Jon Yates - Medical bills caught in former employer's plight
September 20, 2009
Copyright © 2009, Chicago Tribune
http://www.chicagotribune.com/news/columnists/chi-sun-problem-health-insurancesep20,0,6593200.column

Ex-employee is stuck with $15,000 debt after COBRA gets canceled

Bob Dourlain has Type 2 diabetes. His wife is battling thyroid cancer.

So when Dourlain left his job in May, going without health insurance wasn't an option.

The Wheeling resident applied to continue his former employer's group insurance coverage through COBRA and was approved.

He paid the first monthly premium of $898 and assumed his doctors visits were covered. Over the summer, Dourlain and his wife racked up about $15,000 in medical bills, he said.

Then the bottom dropped out.

Before he could make his second premium payment, Dourlain received a letter from his insurer, Blue Cross and Blue Shield of Illinois, saying some of his claims had been denied.

When he called Blue Cross, he was told the shocking news: He no longer had insurance.

After digging further, he learned that his former employer, Zoom Graphics of Schaumburg, failed to pay premiums on the company's health-care plan. Blue Cross, in turn, canceled the plan.

Without the company's plan in place, Dourlain was no longer eligible for coverage under COBRA.

The company administering his COBRA coverage quickly refunded his $898.

And Dourlain was stuck with the medical bills.

By the time he started a new job Sept. 1, which came with insurance coverage, Dourlain and his wife were buried under an estimated $15,000 in medical debt, perhaps more if the doctors bill at non-negotiated rates.

Unable to pay, Dourlain e-mailed What's Your Problem?

"I was definitely confused because everything supposedly had been paid," he said. "Then the confusion turned to anger."

The Problem Solver called Sandip Mehta, one of Zoom Graphics' owners. Mehta said the business has fallen on hard times and has lost or laid off all but 10 of its 60 employees.

He said he stopped paying the company's insurance premiums over a dispute about how many employees he should be charged for.

"There was an accounting error on the main insurance policy," Mehta said Friday. "That is being resolved."

Mehta faxed the Problem Solver copies of three checks totaling $25,129.05 that he said he overnighted to Blue Cross to cover his unpaid premiums. Once the company cashes those checks, he said, the insurance plan will be reinstated, and Dourlain's claims from the summer should be covered.

"I'm not paying it because of you," Mehta said. "I have other claims that needed to be paid too."

The Problem Solver called Blue Cross spokeswoman Mary Ann Schultz, who said she could not comment on Dourlain's case because other employees and former employees of Zoom also are affected by the outcome.

If Mehta sends the check, she said, Blue Cross will restart the company's insurance plan. "Blue Cross and Blue Shield of Illinois' policy is that once an employer group is canceled for delinquency, we discontinue benefits," Schultz said. "Once payment is received, we will reinstate benefits retroactively and adjust claims for payment."

For Dourlain's claims to be paid, he would have to repay the three $898 COBRA premiums from the summer. At this point, he said, that would be difficult.

"My income has gone so down because of changing jobs," he said. "I haven't paid my bills."

Dourlain said he's already begun calling his providers to ask them to write off his charges as a "charity case."

"I'm spending all my free time at night filling out paperwork for the hospitals," said a weary Dourlain. "It's almost the same paperwork as going through a bankruptcy."

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