Recission and the bad old days

Sabrina Corlette is going through all of the conditions that used to be cause for an insurer to either never write a policy or to go back through medical records and rescind a policy once someone got expensive:

 


An insurer only needs to find a diagnosis once in the medical records to attempt to rescind in the pre-ACA days.  Even if that diagnosis was wrong, if it was in the records and the current set of claims was expensive enough, an insurer could fight for years to throw a person off of coverage.   Gout leaped out at me as it triggered a memory.

About four years ago, I was refereeing an adult soccer tournament.  I like this tournament as I get to see and work with a bunch of really good referees for some pretty good games and we have fun.  I showed up to the fields on  Friday afternoon, did two evening games and then went out with the crew for burgers and a few beers.  The burger was amazing.  Half a pound of beef with some blue cheese crumbles and a couple of local IPA’s.  It is one of the better burgers I’ve had.

Saturday was a full day on the field.  I ran six games, four on the line and two in the middle.  It was hot, it was humid and as the fields got used, the surface got worse.  After the last game, we again went out for a burger, a beer and some no-shit story telling.

Sunday morning I only had two games before I could go home.  First game went fine, Over-23 women who were still in good enough shape to play a full ninety.  I had the middle and in the 87th minute, my left foot tweaked a bit on a divot in the field.  No big deal, I stretched it out at the end of the game and got ready to go to my pre-game for the line I had to run.  This was a men’s open game with mostly former PDL players so it was an up and down game with a well disciplined defensive line that had no problem running a thirty yard sprint trap (bastards).  My left foot was not feeling great.  And then it failed.  I attempted to stop an upfield run, plant hard and change direction to a full sprint to the goal line.  My foot folded in on itself and it hurt like a bastard with eight minutes left.

Thankfully the game was out of reach (3-0).  I hobbled for the rest of the game and then hopped to the referee tent.  A friend of mine is an athletic trainer.  She looked at my foot and said it was either a break or an arch sprain.  I should get an x-ray.  I got into my flip flops and drove the the local urgent care center.

At the urgent care center, I said my left foot near the big toe was in extreme pain.  The clinician asked if I had any red meat or alcohol this week.  Yes, I had two burgers and three beers since Friday night.  “Mr Mayhew, you have gout”  This was within the first two minutes of the examination.  I protested, explained that it was a sports injury and an atheletic trainer thought the problem was either a sprain or a break in the metatarsal.  “Mr. Mayhew, you have gout, here is your scrip and you don’t need an x-ray”

Bull — I made an appointment with my PCP for Monday morning.  He looked at my foot, ordered an X-ray and determined it was a nasty sprain where 6 weeks of PT would be needed.  He saw in my electronic health record that I had not filled the scrip for the gout medication and saw the diagnosis for gout.  He thought it was absurd and ordered a uric acid blood test for me.  I got the results the next day and mine were low-normal.

I had a structural skeletal injury not gout.  The mis-diagnosis did not effect my treatment or recovery.  It did not effect my eligibility for coverage as I am covered through work.  However if I was to go on the pre-ACA underwritten individual insurance market and I ran up $100,000 in claims, that gout diagnosis would be a probable hook for a pre-ACA insurer to rescind my coverage.  I would probably win eventually but I would be fighting for a year or more and running up large legal expenses for a bad diagnosis.






46 replies
  1. 1
    ArchTeryx says:

    And this is a huge part of why what’s coming in January has me so frightened. I have the potentially fatal remnants of an autoimmune disease as serious as lupus. That’s the mother of all pre-existing conditions. No insurer would touch me.

    But it gets far worse from there.

    I’ve got some reason to believe my condition is part of why I’ve been unemployed for three years (and yet, still not a complete enough disability to actually get SSDI/SSI!). I’m also getting signals that Canada would deny me a visa due to the same pre-existing condition – they don’t want expensive poor people as immigrants, natch – and France under Sarkosy isn’t that much friendlier. (At least in France’s case, I have a sister and her husband that both work, in varying capacities, for the French government, so she and an immigration lawyer can at least make a real fight of it).

    The idea that I may have no place left to run to to get my medical care scares the ever-living shit out of me. I’m trying to keep my war face on, though, instead of sinking back yet again into despair.

  2. 2
    Weaselone says:

    What can you say. It’s what the majority in a subset of states with a majority of the electoral votes voted for.

    May those who voted for Trump get both their share of that of those who voted for Hillary.

  3. 3
    Ohio Mom says:

    My outlook changes from hour to hour, day to day. Today I’m convinced they will go for Medicaid first, which mean at the moment I’m most afraid of my disabled kid losing his Medicaid and his Medicaid Waiver (which pays for assorted living expenses).

    But yeah, the three of us in my family are a walking list of pre-existing conditions. So that too.

  4. 4
    VFX Lurker says:

    In California, a couple can purchase guaranteed-issue group coverage if they can qualify as a two-person business. In 2010, I signed a general partnership agreement with my own spouse, got an EIN, got a DBA, opened a business checking account and successfully applied for Kaiser coverage. The insurance broker who walked us through the process said he had done this for “hundreds” of married couples. It worked.

    However, if either of us had died in a car accident, the survivor would have lost coverage. In California, a business needs a minimum of two employees to purchase guaranteed-issue coverage. It was a hack of existing state law, and not a true solution like the ACA.

  5. 5
    HRA says:

    I am a retired NYS employee since the end of 2014. I chose to keep the health insurance (family plan) I signed onto when I worked. I also have the dental and eye care coverage under the union which I pay for quarterly. Friday I received a notice from the health insurance company stating it was compulsory for me to have Medicare Advantage by 12/2 or the coverage will be dropped for 2017. I looked up Medicare Advantage and concluded it has to be our prescription medication that is pushing me to get this coverage. I have 3 scripts I rely on. My husband has around 3 times the amount.
    Yes, I will be calling the insurance company for more information. I also have to call NYSHIP as well for more information.
    PS My husband is already ranting it has to be ACA driving it. I disagree. Who could be right?

  6. 6
    CaseyL says:

    If your state has an Office of the Insurance Commissioner, or anything like that, you might try contacting them to see if the state you live in, or the insurance companies doing business in your state, have any contingency plans if ACA and Medicare are lost.

    (I apologize in advance for offering useless information if you’ve already done this.)

  7. 7
    PST says:

    I have an example, this goes back to the 80s, that illustrates just how unfair this practice could be. The mother of one of our son’s friends was diagnosed with colon cancer, a disease I have since learned all too much about. She was insured through her husband’s employer. He made an ordinary job change. I believe that there was no loss of continuous insurance, but it has been a long time and perhaps there was a short gap. Although she was not diagnosed with colon cancer before the change in coverage, her medical records showed complaints of symptoms that, viewed in retrospect and with regard to how slowly a colon tumor grows, made it clear the cancer was present earlier. Therefore the company attempted to deny coverage based on a preexisting condition. Eventually they backed down, but the company kept up such a constant rear-guard action against covering her expenses that the whole family moved back to her native land, a normal western European country where this kind of crap is not tolerated. I don’t want to see those days again.

  8. 8
    Percysowner says:

    @Ohio Mom:

    My outlook changes from hour to hour, day to day. Today I’m convinced they will go for Medicaid first, which mean at the moment I’m most afraid of my disabled kid losing his Medicaid and his Medicaid Waiver (which pays for assorted living expenses).

    I think you are probably right, however, Medicaid, not Medicare is what covers most nursing home bills. The Republicans will be a bit leery (maybe, I hope?) of having thousands of aged people dumped on the streets. The aged won’t like it. Their kids aren’t going to appreciate having mom and dad show up on their doorsteps needing a place to live. That doesn’t mean they won’t keep the nursing home for the aged coverage and screw your disabled kid, but it might keep them from totally ripping Medicaid away.

  9. 9
    JCJ says:

    Yup. My daughter was diagnosed with lupus right after her 21st birthday. The usual medications, (hydroxychloroquine, azathioprine, methotrexate, NSAIDs) did little other than cause toxicity. Belimumab (Benlysta) has worked very well for her, but she still has no energy and occasional days where getting out of bed is a monumental task. My previous plan was to have her on my insurance for one more year and then buy insurance for her after age 26. Now the plan is to try to apply for disability.

  10. 10

    There are some folks here collecting pre-ACA stories on a Tumblr but I can’t recall the address. This would be a good time for a link, maybe even in the OP!

  11. 11
    Gin & Tonic says:

    @CaseyL: Insurance in the United States is a state-regulated business, so every state has some equivalent regulatory agency. The web site of the National Organization of Insurance Commissioners is a good place to start.

  12. 12
    Villago Delenda Est says:

    That clinician was desperately looking for some reason not to have to treat you.

  13. 13
    Basilisc says:

    Well obviously you wouldn’t have this problem if there were health savings accounts. And letting insurers sell across state lines. Oh, and lower malpractice awards. [/snark]

  14. 14
    patrick II says:

    I particularly remember a case in Texas where a lady who developed breast cancer was dropped because she once had acne and had not reported it as a pre-existing condition when they bought the insurance, so they dropped her. There were appeals, etc., but each day/week/month she did not receive treatment the clock was ticking — to the benefit of the insurance company at the potential cost of the life of the lady. I do not remember how it turned out — but the ruthlessness was amazing.

  15. 15
    Patricia Kayden says:

    @ArchTeryx: If you tried to emigrate to Canada, would you have to reveal that you have any medical conditions? I don’t recall that being a question when I emigrated to the U.S. I recall when my Jamaican Grandmother lived with us in Canada, she had no problems at all getting healthcare coverage (but perhaps because of her connections to my Dad).

    On a lighter note, Trump promised after meeting with President Obama to keep certain parts of the ACA including coverage for people with pre-existing conditions. Perhaps he’ll keep that promise and you won’t have to worry.

  16. 16

    And the state insurance commissions are slow as molasses and underfunded and undersupported in most state legislatures, so rather than aggressively defending the life and health of the patients they just leave the problems to the patient and patient’s families.

  17. 17
    WereBear says:

    @Major Major Major Major: The “Tell us your healthcare story” website is:

    Could Happen to You

    and thanks!

  18. 18
    WereBear says:

    @patrick II: Would any of the millions of people who had acne even think of reporting that as a “pre-existing condition”?

  19. 19
    Villago Delenda Est says:

    @Patricia Kayden: Like Donald’s promises are any good. Ask anyone who’s contracted with him. They’re all just “scraps of paper” to him.

  20. 20
    iwritesometimes says:

    @Major Major Major Major: hey there! that tumblr is It Could Happen to You.

  21. 21
    Pogonip says:

    @WereBear: I certainly wouldn’t.

  22. 22
    WereBear says:

    As I explain to people, Obamacare isn’t about giving slackers something for free, it is a cost-containment measure that keeps employer provided healthcare, and Medicare, running. Everyone has a stake in this.

    And I’ve heard of people with a health condition who are now unemployable; companies don’t want to take them on. Like they don’t have enough to deal with.

  23. 23
    Villago Delenda Est says:

    @patrick II: This is the sort of shit that should result in tumbrel rides for insurance execs.

  24. 24
    Patricia Kayden says:

    @Villago Delenda Est: I’m trying to have an open mind like some Democratic leaders have recommended. (Not really. Just hoping that he keeps this particular promise given how awful the alternative would be).

  25. 25
    daverave says:

    That twitter link is just one tweet out of 20 or so that lists all of the disqualifying pre-existing conditions… who doesn’t have or hasn’t recently had one of those conditions? Scary. I’ve got/had several. I challenge the BJ readership to read the list and post here if you’ve haven’t experienced at least one of them in the last five years.

  26. 26
    p.a. says:

    Josh Marshall on a tangent to ACA, but another critical program, and critical to Dems being able to hold the line as much as possible: Medicare.

  27. 27
    Juice Box says:

    I’ve got many of those pre-ACA stories to tell. At least one ends in death. Heck, back in the late 80s, I can remember my employer not wanting to rehire a really good engineer with a pregnant wife in order to keep health insurance cost down.

  28. 28
    WereBear says:

    @daverave: Not only that; your entire medical record can be combed for “evidence” of pre-existing conditions. Tummy trouble? Now they are off the hook for hundreds of expensive conditions that have that as a component.

  29. 29
    Yoda Dog says:

    How the fuck is he going to keep pre-existing conditions while rescinding the mandate? He doesn’t even know what the fuck he’s talking about at all. Half the time he sounds like he’s describing a fucking insurance plan when he refers to the ACA…. Fuck me how has it come to this?

    My parents are apoplectic after voting for orange fuckface and now they’re finding my shoulder quite cold… Well, fuck their feelings, Im too busy worried about how the hell Im going to insure my family to worry about their goddamn feelings.

  30. 30
    VFX Lurker says:

    @Villago Delenda Est: Insurers can’t print money. They can only collect premiums. If their premiums get too expensive, they lost healthy customers to insurers with cherry-picked pools of healthy subscribers.

    The pre-ACA system encouraged ruthless and cruel outcomes while the healthy subscribers looked the other way.

  31. 31
    Villago Delenda Est says:

    @Yoda Dog: That’s precisely the problem. Shitgibbon does not understand how any of this works, in part because he’s had enough spare cash in the bank account to deal with this crap, usually borrowed from someone else, as he spent his dad’s inheritance on gold leaf, a yacht, and a failed football league. One that he deliberately set up for fail

  32. 32
    Villago Delenda Est says:

    @VFX Lurker: Hookers and blow won’t pay for themselves, in short.

  33. 33
    VFX Lurker says:

    @Yoda Dog: Five states had bans on preexisting conditions without an accompanying mandate. Their premiums ran high because too many healthy people opted to not buy insurance when they got sick. Massachusetts had the highest premiums in the nation when they finally broke down and implemented a mandate in 2006.

  34. 34
    Pogonip says:

    Most Americans have no idea that these horror stories are not normal. I suggest also adding stories from citizens of countries that have sensible medical systems.

  35. 35
    Yoda Dog says:

    @VFX Lurker: Ahh yes, you mean like MYYY new insurance plan…. It doesn’t cover shit but the premiums are very affordable!

  36. 36
    Pogonip says:

    P.S. I meant, not normal everywhere. They are normal here and that’s why it may help for Americans to see stories from elsewhere; if enough people start wondering “Why do I have to put up with insurance-company bullshit? No one else does” they might get angry enough to contact their congresscritter.

  37. 37
    kirbster says:

    @Pogonip: PBS made a Frontline documentary called “Sick Around the World” back in 2008, showing how universal health care was working in other countries…I don’t know if it’s online anymore.

  38. 38
  39. 39
    Ohio Mom says:

    @JCJ: I applied for disability for my kid (SSI) and was successful. Lots of people aren’t and are rejected, even ones who have very good cases. My advice to you is to consider consulting with an elder care/disability attorney first. Also, if your daughter has more than $2,000 in her name, it will need to be sheltered in a trust. To sign up for SSI is to agree to be poor.

  40. 40
    EBT says:

    Worth pointing out that being trans is enough to be denied coverage for any and everything. Because it’s so poorly officially understood they just say whatever your problem is, results from trying experimental treatments.

  41. 41
    VFX Lurker says:

    @EBT: Thank you for pointing that out. I had no idea. That’s horrible.

  42. 42
    EBT says:

    @Ohio Mom: Don’t bothering applying on your own. I had a social worker who had specialized in SSI applications for a decade and medical records dating back to age 4, and it still took a denial and a couple years.
    @VFX Lurker: Friend had to pay for a broken bone out of pocket because of being trans.

  43. 43
    Brachiator says:

    @BigHank53:

    The Frontline show is here:

    Thanks for the link.

    I guess that people should be ready to write to Congress once the new Congress is in session. There seem to be some common areas of concern that might make up any communication, pre-existing conditions, prescriptions, etc.

  44. 44
    quakerinabasement says:

    Yes, I had two burgers and three beers since Friday night. “Mr Mayhew, you have gout”

    If that’s all it takes, I ought to be a walking mass of gout.

  45. 45
    Ohio Mom says:

    @EBT: Wow, that is quite the wringer you went through. My kid was approved fairly quickly (eight months) but I live with the knowledge that his case will probably be up for renewal review one day, and then the anxiety and paperwork starts all over. Even though there shouldn’t ever be a question about his eligibility.

    USAians …we can be such a mean-spirited people.

  46. 46
    amygdala says:

    God, I have a million of these stories. Years ago, I took care of a young woman with intractable migraines. Took awhile to get them under some sort of control and because they started rather abruptly, we did a workup for more ominous causes of headache and admitted her for aggressive therapy to try to break her headaches. Or, put another way, the public system paid for the expensive parts of her care. Eventually we found a preventive agent that she could tolerate–she had a lot of side effects with the usual meds–and that got her headaches from a 7-8/10 severity to a 4. Not optimal, by any means, but she was able to go back to school and work part-time. She was a trooper. I had finagled a way to get one of the big dogs in the field to look in on her, to make sure we hadn’t missed something, and for any other insights he might have. He agreed with our treatment plan.

    Flash forward a few years (still pre-ACA). She was working for a small business and wanted to get insurance on the individual market. I’d see her once a year, to renew her meds and for a quick checkup. She’d see her PCP for routine health care maintenance. I wrote a half-dozen letters to several insurers when she got turned down for coverage. No one would cover her. She quit her job, to work for local government, in order to get coverage.

    Because of the things Mayhew described above, I spent hours counseling the residents about being careful in what they documented in charts, when there was uncertainty. I understood their wanting to lay out their thinking–it makes for better patient care to do so, under many circumstances–but it takes being an old clinician to understand how easily that makes a person uninsurable. Under the ACA, at least folks could now get health coverage, but thinking aloud in a chart can make it impossible still for someone to get disability or life insurance.

    I hate to think about what it will be like if Ryan, enabled by Trump and Pence, gets his way.

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