Insurance executives held out hope to the afflicted late last month by announcing their willingness to end a notorious industry practice: charging higher premiums to people with health problems or denying them coverage altogether.
But don’t breathe easy just yet. The change, promised at a Senate hearing, would hinge on the condition that Congress in turn require everyone in the land to carry health insurance. And Congress is still at least months away from taking up major health legislation.
So for now, consumers with pre-existing medical conditions must continue the struggle to obtain and keep medical coverage.
“It is arguably the biggest minefield out there when it comes to getting and keeping your health insurance,” said Karen Pollitz, project director at the Health Policy Institute at Georgetown University. “Under the current system, the people who need insurance most can’t afford or can’t get coverage.”
Until the system changes, here is basic guidance for people with pre-existing conditions, whether you’re currently covered or shopping for insurance.
TRY TO KEEP EMPLOYER’S COVERAGE
Under the Health Insurance Portability and Accountability Act, known as Hipaa, employers cannot exclude you from a health plan because of a pre-existing condition. They must offer you coverage and pay the same percentage of your premium as they do for healthy employees. The same rule applies to spouses and children if the employer offers family coverage.
Keep in mind, new employees can be denied coverage for treatment related to their pre-existing conditions for up to 12 months. But if you have had continuing coverage from another group plan, the amount of time you held that coverage can be credited to the 12-month exclusion.
More troublesome is if you had a gap in coverage of 63 days or more. In that case, employers can exclude coverage of your health problem for up to 18 months, but then must give you full coverage.
LEARN YOUR STATE’S RULES
Not everyone can get insurance through an employer, of course. And that’s when things get tricky.
In reality, most insurers deny individual coverage to sick people. As a safety net, federal law mandates that each state offer at least one nongroup, or individual, option that cannot deny anyone coverage. The details vary from state to state.
To find out what’s available where you live, check with your state’s insurance department. Contact information for each state can be found at the Web site of the National Association of Insurance Commissioners, www.naic.org/state_web_map.htm.
Cost is a big problem with all of these last-gasp policies, said Sandy Praeger, the insurance commissioner for Kansas and chairwoman of the national association’s health insurance committee. Because there are no federal laws regulating premiums, they can be prohibitively expensive. “Unfortunately, there aren’t many affordable alternatives,” Ms. Praeger said.
If you do find yourself turned down by an insurer for a pre-existing condition, you can appeal that decision. With your doctor’s help you may be able to convince a carrier that denied you coverage because of, say, high blood pressure, that you now have the condition under control.
SEEK OTHER GROUP COVERAGE
Even as an individual, you may be able to join a group health plan, especially if you run your own business. Your chamber of commerce may offer health coverage for local business owners. And professional and trade associations sometimes offer group insurance to qualified members regardless of their health.
But “be very careful when dealing with associations,” Ms. Pollitz warns. “This has been an area riddled with fraud and insolvencies.” Check out any potential group carefully with your state insurance department.
You may also want to research group purchasing alliances in your state. In these, small businesses band together to buy group health insurance plans at rates that might otherwise be available only to big employers. Check with your state insurance department on how to join an alliance — or to form a new one.
IF COVERAGE IS TERMINATED
If you seek treatment for a health problem under an individual insurance plan, the insurer may look into your medical history for proof that you had the problem before applying for coverage, said Kevin Flynn, president of HealthCare Advocates. His company, in Philadelphia, works with patients who are in dispute with their insurers.
Insurers also may review your application and determine that you omitted important information related to a pre-existing condition, Mr. Flynn said. If the insurer finds evidence of either transgression, it may rescind your policy.
That’s what happened last year to Melissa Klettke, a 26-year-old who lives near Portland, Ore. Because her employer’s group insurance was expensive, Ms. Klettke shopped for a less expensive individual policy. Finding one online, she applied and was accepted.
About three weeks after getting coverage, Ms. Klettke began having symptoms that her doctor worried could signal multiple sclerosis. Terrified, she started a battery of diagnostic tests including expensive M.R.I.’s and consultations with a specialist.
Amid all this, her insurer wrote to say her coverage was being dropped because she had failed to disclose a trip to the doctor months earlier during which she complained of vertigo. That, the insurance company said, was proof of a prior condition.
“Here I was, scared to death, not knowing what was going on with me, and then I find out I have no insurance,” Ms. Klettke said.
The good news is that Ms. Klettke does not have multiple sclerosis. But she has paid about $5,000 out of pocket for tests and doctors’ fees. Happily, though, she recently got a new job at a shipping company that offers health insurance, and she is covered under her employer’s group plan.
Although Ms. Klettke got nowhere with her appeals to the former insurer, Mr. Flynn urges people who find themselves in her position to push back. Ask your doctor for help in proving to the insurer that the reason you were dropped is not proof of a pre-existing condition.
Mr. Flynn recalls a client who lost his insurance because he had been treated for a canker sore on his tongue six months before he was diagnosed with mouth cancer. “We were successful in reinstating coverage when his doctors made it clear the two things had nothing to do with each other,” he said.
Make your appeal in writing first, then follow up by phone, Mr. Flynn advises. If you get the chance to make your case in person, by all means do so, he added. And always file a complaint with, and enlist help from, your state insurance department.
BEWARE OF TEMPORARY POLICIES.
Relatively inexpensive policies offering coverage for a limited period, usually six months to a year, have become a popular alternative for people who may be out of work but hope to soon have a job with employer coverage.
But if you get sick or injured while holding one of these policies, Ms. Pollitz said, the insurer will most likely deny you coverage when you try to renew — because now you have a pre-existing condition. If possible, she said, you’re better off paying for a longer-term, more comprehensive policy.
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