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The results are in!
Featured in: A Patient's Journey
The results of the poll are in, and they're not very encouraging, at least not from my stand point.And they are not encouraging!
Of 41 votes cast (which is a disappointment in itsef), in the poll I posted on October 20, 2006, 25 people believe health care should be treated as a commodity, and only distributed to those who can pay.
I can only hope they are not representative of US society as a whole.
It may appear to some, that I have become a little obsessed with this topic, but as someone with a serious, chronic condition, I tend to look at things a lot differently then the majority of the population who think of themselves as healthy.
Up until my diagnosis, I had never been sick (serious sickness that is) a day in my life. Sure I had to go to the doctor for the occasional infection, bike accident, and work injury, but other than that, I have never really been sick.
Even to this day, I consider myself in excellent physical condition. I still cycle competitively, riding my bike approximately 150 miles per week (depending on the time of year), and I take absolutely no medication of any kind. I will admit to taking an antibiotic, and one (1) Vicodin (which I will never do again) after my most recent bicycle accident, resulting in a hugh gash in my ankle requiring several stitches, but that is the extent of the medication I have taken.
So I never had to worry about the possibility there could ever be a problem with my not having health insurance for any length of time, that is, until my diagnosis.
But when you contract a serious illness, you quickly learn how vulnerable you are to so many things of which you have little or no control over.
You quickly learn that health care providers don't always have your best interests at heart.
You learn how flawed reimbursement policies by the government and health insurers, encourages the performance of unnecessary tests and treatments, to recover costs, resulting from an unfunded government mandate to provide free health care to anyone who needs it, regardless of their ability to pay, which are then shifted to everyone who purchases health insurance, or can afford to pay for health care on their own.
You also learn the health insurance you though was so great, when you only were experiencing minor health problems, can so easily turn against you by denying needed coverage for the flimsiest of reasons, in the hopes that you will die, while you try to seek restitution in the US court system,
And you learn how easily you could become destitute, losing everything you worked so hard to achieve in life, even being forced into bankruptcy, should you lose your job, or become unable to work, and can't afford the cost to maintain your health insurance.
Hopefully, as the population ages, and the healthy begin to realize, even they won't be that way forever, and will have to eventually deal with a health care system, that doesn't always work in their best interest, things will change.
Until then, I guess the US will remain the only country in the industrialized world, that continues to believe only the rich should be entitled to receive health care.
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I have mantle cell lymphoma, and to be so bold as to quote a line from another blogger "it may kill me." Actually it is killing me, albeit very slowly at this point. In the mean time, I'm still able to function mostly as normal, going to work, riding my bike, playing golf and even planning for vacations.
In fact, if it wasn't for that fateful blood test of March 26, 2002, I still might not even realize I am sick.
But that isn't the case, so I decided to chronicle my life from the beginning (not from when I was born, mind you, but from that fateful day), and remembering it's not just about being sick. Even if you've been diagnosed with a terminal illness, that doesn't mean life ends.
We're all going to die, most of us just have different perspectives on when that is going to happen. It's how we deal with the living part of our lives, that makes a difference.
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Comments (14)
#2: WOW!
I certainly understand your pain, and no one should have to spend their last dime, and face bankruptcy because they get sick.
But it seems to me you may have brought some of this on yourself. Now I don't mean to be uncaring, because I'm not, but I am just a little confused, by the fact that you just applied for insurance last year.
From what I've gathered from your comment (eligible for Medicare in 2037) you are 34 years old. Have you been without insurance for the past 10+ years? (not HIPAA eligible) Why is that? Did you think you wouldn't get sick? And then why all of a sudden did you apply for it?
I can certainly understand Pacificare's position thinking that you knew you had cancer all along. I might even be persuaded to believe it, based on the facts you presented.
Now that doesn't mean I condone what Pacificare has done, nor do I condone a system that allows that to happen, but if you had insurance all along, you would not have been in your current situation.
But still you are right, you are the perfect example of what can happen under a system where health care is considered like any other commodity, and available only to those who can afford it, or are totally destitute, and on the government dole.
Marc
MLKashinsky.com
As I was riding my bike this morning I think I realized the point of your post.
You were one of those healthy 80% of the population, who didn't think they could become one of the sick 20% of the population, and you just learned how the system works.
That's a good lesson for everyone to learn, before it's too late.
Marc
MLKashinsky.com
Hi Marc,
Let me explain how this all came about. I was laid off from my software related job in late August 2003. I was in a Group Plan through my employer with full coverage at HealthNet. Following my layoff, I was on Cobra for a few months. I stopped coverage because the monthly cost was almost $400 per month which I could not afford. I figured it was a waste since I never went to the doctor for anything.
Since I had this unexpected free time, I decided to take that trip to Europe I had always wanted. I have family all over Europe, so I spent a couple of months visiting family and traveling.
When I got back, I started training to upgrade my skills and opened a small business consulting and hosting company. One of my clients asked me to evaluate their Worker's Comp Insurance as well as their CGL policy. I met with the broker they had chosen and happened to mentioned that I needed Health Insurance. It just so happened that he was also a broker for health insurance as well.
From November to February, the broker and I had meetings regarding the insurance coverage for our mutual client. These meetings were spaced apart about every 4 ot 5 weeks as the current policies expired.
The first app I filled out was on December 7th and was for HealthNet since they were my last provider, I figured it would be easier. The broker convinced me that the Pacificare plan was better so at the next meeting he gave me a Pacificare App. I gave him that App on Jan 10. On Jan 18th, he sent me the 2006 App because Pacificare would not accept the 2005 App.
And the story goes from there. I did not have any symptoms whatsoever when I had that full body scan. I didn't even consider it a visit to a doctor. I viewed it more as a high quality technology to put to rest any issues regarding my dads health. The ladies who worked there even mentioned to me that it was very rare for them to see a 33 year old in their office. Thank God my dad asked me to go with him!!
BTW, my trip to Europe did not cost me a dime. I come from a big Italian family that is spread out all over Europe. When they visit the states, I always did my part to take them somewhere like San Francisco or Las Vegas. They were always greatful and extended an open invitation to visit them in Europe whenever I wanted. I could never thake them up on their offer because I could not take the time off from work, so when the opportunity presented itself, I took it. I didn't want you to think I could afford thousands of dollars for a trip to Europe but not for Healthcare.
but it really comes down to this: you (apparently) submitted a fraudulent application.
When one cuts thru all the static, it's a pretty simple timeline: You had a full body scan on January 13th, and submitted an application on January 18th. Unless you disclosed the scan on that application (it doesn't really matter that you "didn't even consider it a visit to a doctor;" it obviously was), then you materially misrepresented your health history on that app. Thus, the rescission.
Three other items:
First, I think that Marc has done a remarkable job in assessing the situation as a whole.
Second, you indicated that a client had asked for your input on insurance matters, which you agreed to supply. I infer from this that you have a better-than-average working knowledge of how insurance works, which means that you had to have known better than to submit that second app without full disclosure. Alternately, your client was ill-served by you, since you apparently lack the expertise on which he was relying.
Lastly, if your version is accurate (which is not necessarily the case), your agent did you no favors in filling out the second app on your behalf. Ultimately, of course, your signature on it warrents that the answers were accurate, which -- of course -- they were not. You may have a cause of action against the agent (E&O claim), but it will be very difficult for you to prevail.
Okay, one more thing (and this is mostly for "lurkers" who may be reading this): you have mischaracterized how HIPAA and COBRA really work. This is no surprise: most folks really don't understand them. HIPAA only helps you in going from individual to group, not vice-versa.
I will rebut each of the contentions raised by hgstern.
The first one being that I submitted a fraudulent application.
The definition of fraud is as follows:
If I had scheduled the full body scan because I was having symptoms that required me to seek medical attention, then that would have been fraud because I did not disclose those symptoms on the application.
The fact is that there was no reason for me to have this scan whatsoever.
The question on the application asked "Has any applicant listed on this application seen a Medical Practitioner, for any reason, in the past two years?" On January 10, I answered no to this question. The broker transferred this answer on to the Jan 18 application. The answer of "no" was still a truthful and correct answer on January 18 because in fact I had no reason to see a Medical Practitioner to have the scan on January 13.
Your contention that "you materially misrepresented your health history on that app. Thus, the rescission." is incorrect.
In California, in order to effect a proper rescission, Pacificare must establish a willful misrepresentation.
A retired Insurance Investigator from the California Department of Insurance reviewed my case and concluded that Pacificare had no right to recind my policy.
Your next contention is that I should have known better since I was helping a client with insurance matters. I should have elaborated further regarding my capacity as I was in no way representing myself as an expert in insurance matters. Rather, since I was providing Business Consulting services, I was asked to help with the process by providing the broker the required information needed to get coverage since the client was out of state and had never owned a business before and may not be available. Since I had experience with dealing with brokers for Workers Comp and General Liability when I owned a restaurant for several years, I could move the process along much quicker for the client.
Your comment regarding the accuracy of my comments is in bad taste and shows your complete disassociation with matters of this magnitude. In fact, I would contend that your post is more of an attack than a statement of actual knowledge or expertise in these matters. As stated in the first paragraph above, my answers on the application both on Jan 10 nand Jan 18 were truthful and accurate. In addition, you have no right to contend that the answers were not accurate when you didn't even know the actual question.
Lastly, for those "lurkers", please disregard hgstern's contention that I mischaracterized how HIPAA and COBRA really work. He apparently enjoys making statements without pointing to actual facts. This is what the letter I received from Pacificare states:
Statement of HIPAA Portability Rights
IMPORTANT
Preexisting condition exclusions. Some group health plans restrict coverage for medical conditions present before an individual's enrollment. These restrictions are known as "preexisting condition exclusions." A preexisting condition exclusion can apply only to conditions for which medical advice, diagnosis, care or treatment was recommended or received within the 6 months before your "enrollment date." Your enrollment date is your first day of coverage under the plan, or, if there is a waiting period, the first day of your waiting period (typically, your first day of work). In addition, a preexisting condition exclusion cannot last for more than 12 months after your enrollment date (18 months if you are a late enrollee. Finally, a preexisting condition exclusion cannot apply to pregnancy and cannot apply to a child who is enrolled in health coverage within 30.days after birth, adoption, or placement for adoption.herefore, once your coverage ends, you should try to obtain alternative coverage as soon as possible to avoid a 63-day break. You may use this certificate as evidence of your creditable coverage to reduce the length of any preexisting condition exclusion if you enroll in another plan.spouse's plan), even if the plan generally does not accept late enrollees, if you request enrollment within 30 days. (Additional special enrollment rights are triggered by marriage, birth, adoption, and placement for adoption). Therefore, once your coverage ends, if you are eligible for coverage in another plan (such as a spouse's plan), you should request special enrollment as soon as possible.based on a health factor.
Under HIPAA, a group health plan may not keep you (or your dependents) out of the plan based on anything related to your health. Also, a group health plan may not charge you (or your dependents) more for coverage, based on health, than the amount charged a similarly situated individual.
If a plan imposes a preexisting condition exclusion, the length of the exclusion must be reduced by the amount of your prior creditable coverage. Most health coverage is creditable coverage, including group health plan coverage. COBRA continuation coverage, coverage under an individual health policy, Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), and coverage through high-risk pools and the Peace Corps. Not all forms of creditable coverage are required to provide certificates like this one. If you do not receive a certificate for past coverage, talk to your new plan administrator. You can add up any creditable coverage you have, including the coverage shown on this certificate. However, if at any time you went for 63 days or more without any coverage (called a break in coverage) a plan may not have to count the coverage you had before the break.
Right to special enrollment in another plan. Under HIPAA, if you lose your goup health plan coverage, you may be able to get into another group health plan for which you are eligible (such as a
Prohibition against discrimination Right to individual health coverage. Under HIPAA, if you are an "eligible individual," you have a right to buy cenain individual health policies (or in some states, to buy coverage through a high-risk pool) without a preexisting condition exclusion.
#8: Again WOW!
I think I may have started something here I didn't mean to.
I was hoping Hank could offer some advice, but it looks as though you are quite capable of dealing with the situation on your own.
But the one thing that I will never understand is why in the greatest country in the world, where we will send billions of dollars to help the less fortunate in the world, we have so little compassion for sick people in our own country.
No one should have to choose between buying health insurance, buying food or having a roof over their heads. No one should have to risk bankruptcy simply because they get sick.
I guess it's true what they say, in America, anything is possible.
But I also think this issue also serves to point out a great misconception that many people have in the US, and that is even if you have never needed health care before, and feel perfectly healthy now, things can change in the blink of an eye.
Eventually everyone will need health care, and everyone benefits from a good health care infrastructure, and in order to maintain it, everyone should have to contribute, much like we contribute to maintaining our police and fire infrastructures
Marc
MLKashinsky.com
"you are quite capable of dealing with the situation on your own."
This is Marc's blog, and I have no intention of causing strife. If the OP believes that his (her?) assessment is correct, then more power to him/her.
Singing lessons over.
My battle with cancer, an insurer that canceled my coverage because I got sick,
Actually, no. Carriers are prohibited from cancelling coverage "because you got sick". They are allowed to cancel coverage when the information on the application does not match reality.
I had first visited with my insurance broker in November, and after some back and forth he persuaded me to go with PacifiCare. I filled out the application Jan. 10
Why did it take almost 2 months to get around to completing the application? Most people can fill in an application in less than 30 minutes.
If I had scheduled the full body scan because I was having symptoms that required me to seek medical attention, then that would have been fraud because I did not disclose those symptoms on the application.
Symptoms or not, it appears you scheduled the exam in December. I am not familiar with the PC application, but most applications ask if there are any tests that have been scheduled that have not yet been performed, or are there any tests performed where you are awaiting results. If you did schedule the test in December and failed to note it on the application it can be construed that you defrauded the carrier.
Last Christmas, he said, OK, “I’ll do it if you do it.” He was more than a little nervous so I decided to humor him. I called the clinic where my mother had gone and they said it would be a couple of months, unless we would go Friday the 13th of January
It would appear this exam was not noted on your January 10th or 18th application.
I am not unsympathetic to your situation, but the facts do not support your contention that PacifiCare is to blame. You chose to drop COBRA, and chose to wait another 2 months from November 2005 until January 2006 before finally pulling the trigger. The carrier has every right to suspect fraud. You have every right to challenge their decision.
And as Hank has pointed out, while the agent may share some blame, you were the one who signed the app attesting to the accuracy of the information.
The fact that I started the enrollment process in November and finished in January proves that I was not in a hurry to get coverage because I needed to defraud an insurer. Also, the only reason I had that scan on January 13 was because no one else would book that day because it was Friday the 13th. It was either that day or wait 2 months for the next available date. Since I had been trying to get my dad to have the scan for 6 months, I figured the quicker the better. If I would have been superstitious, I would have saved myself a lot of grief it seems.
When I had the scan on the 13th, I had no symptoms and it was not done for any medical reason whatsoever. I did not have the results of this scan on the 18th and did not schedule a follow up consultation to go over the results.
When on was told by phone on February 3 that I had a tumor, I did not hide the results of this scan from my doctors. As a matter of fact, when I met with my PCP I gave him both a paper copy of the report as well as a CD that contained a 3-D holographic fly through video of the entire scan.
When I was referred to the Urologist, I also provided him with both a written report and the CD images as well. The doctor who gave me the second opinion was also given the written report and the CD. When I met with the Oncologist, he was also made aware of the scan that found the tumor, so there was no intent here to decieve which California Law requires.
Every doctor I had seen within the plan had a written report and CD images of my scan and all of them knew that my coverage started on February 1, 2006 as each had to verify coverage for a new patient.
Even with the written report and CD images, the Urologist and my PCP ordered an additional MRI to confirm diagnosis as well.
I think that if you knew the entire hell I have gone through, maybe you might think different. My lawsuit was filed yesterday against UnitedHealth and Pacificare. The complaint explains the situation and provides more detail on my entire saga with this HMO.
You can read it here.
SBD
#12: I sure hope you win!
I am certainly not a lawyer, but it seems you have an up hill battle. The coincidences here, IMO, just lean in favor of the insurance company.
The real problem is this should never have happened in the first place. It would not have happened in any other country in the world. The fact that health insurance companies are permitted to operate the way they do is travesty. Playing with peoples lives for the sake of profit is just not right, maybe even immoral
Everone needs health insurance, and everyone benefits from a good health care infrastructure, so everyone should pay for it. Health insurance should be a mandate for everyone in the US. There should not be an option to go without.
If there were, you would not be in this mess.
Good luck!
Marc
MLKashinsky.com
re-examine your priorities on this: he lied on an application. It's really that simple. Don't you think that flagrantly flaunting the rules -- in ANY system -- would put a person in a "mess?"
"I didn't mean to speed, officer; actually, it's someone else's car and I'm not even in a hurry."
Think that'll get me out of a ticket?
How about in a "civilized" country?
See article in Dec. 29 2006 Wall Street Journal by David Wessel,Bernard Wysocki and Barbara Martinez. Also refer to the entire series in the Wall Street Journal. "Health Care Goldmines. Middlemen Strike it RIch. I am unable to attach the link here, so you will need to look it up. Sorry
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Author: Details
First Name
Marc
Middle Name
L
Last Name
Kashinsky
Degrees
BSMME, MBA
Short Bio
I have mantle cell lymphoma, and to be so bold as to quote a line from another blogger "it may kill me." Actually it is killing me, albeit very slowly at this point. In the mean time, I'm still able to function mostly as normal, going to work, riding my bike, playing golf and even planning for vacations.
In fact, if it wasn't for that fateful blood test of March 26, 2002, I still might not even realize I am sick.
But that isn't the case, so I decided to chronicle my life from the beginning (not from when I was born, mind you, but from that fateful day), and remembering it's not just about being sick. Even if you've been diagnosed with a terminal illness, that doesn't mean life ends.
We're all going to die, most of us just have different perspectives on when that is going to happen. It's how we deal with the living part of our lives, that makes a difference.
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Sal D’Anna, Spring Valley, CA
My battle with cancer, an insurer that canceled my coverage because I got sick, and tens of thousands of dollars of debt started out as a compassionate joke.
My father was having health problems that his doctor didn’t understand, so I suggested that he go get a full body scan, something my mother had done a few years ago. Sometimes it finds hidden things.
Last Christmas, he said, OK, “I’ll do it if you do it.” He was more than a little nervous so I decided to humor him. I called the clinic where my mother had gone and they said it would be a couple of months, unless we would go Friday the 13th of January. We’re not superstitious, so that was fine with us. A friend and his wife went with as well.
I thought I was there just to support my Dad. Unlike him, I didn’t even order a consultation with the doctor afterward. This was his appointment, not mine. About a week later, we went in to go over his results, and the doctor said my dad was fine but that she needed to talk with me. She said there was something odd, and that she wanted me to do an abdomen scan that would provide more detail.
We did that on Jan. 31. I got the results on Feb. 3 over the phone. They said there was a definite tumor on my right kidney and they thought I should get right to my doctor. There was no discussion yet of cancer. At that moment, I was certainly grateful that my new insurance with PacifiCare had kicked in. They approved it on Jan. 24, taking effect Feb. 1. It wasn’t until a good deal later that I learned that I had an aggressive form of kidney cancer and that one of my kidneys would have to be removed. This was done May 12.
I had first visited with my insurance broker in November, and after some back and forth he persuaded me to go with PacifiCare. I filled out the application Jan. 10, but on Jan. 18 he told me I had to submit an updated 2006 form. But he told me just to fill out the authorization pages and he’d fill out the rest from my previous application.
On Aug. 13, I got a cancellation notice from PacifiCare. It said that I knew when I applied that I had kidney cancer, and accused me of fraud. If they had called the agent they would have learned I started the enrollment process in November, and the agent knew I was going to have the scan. But I wasn’t diagnosed with cancer until after the coverage actually started. If I’d known I was ill, wouldn’t I have bought something better than a crummy HMO?
At the end of August, I received my regular monthly premium notice for the month of September. I sent the payment certified mail with return receipt and they cashed the check right away. When I did not receive the October premium notice, I sent the October payment to them certified mail with return receipt. I know they received it but have not received confirmation if they had cashed this payment yet.
Also in August, I received two certificates from Pacificare. The first certificate was for HIPAA coverage which is useless since I need 18 months of prior coverage for HIPAA to apply. The second certificate was proof of previous prescription drug coverage so that I won’t get a penalty when I apply for Medicare Plan D coverage. This seemed odd since I won’t be eligible for Medicare until the year 2037. Since I signed up for coverage with Pacificare, I have also received an AARP card and a letter from Liberty telling me how they can deliver my Medicare drugs right to my home. Why they think I am eligible for Medicare is beyond me.
In addition, not only have I had to put with PacifiCare’s illegal, arbitrary cancellation of my policy, but my doctors failed to accurately diagnose my cancer, delaying the correct treatment and wasting precious time. As if that wasn’t enough, PacifiCare refused to pay the bills for my kidney surgery by the experts at the Cleveland Clinic because it was not in the company’s network. PacifiCare didn’t tell me that it wouldn’t cover the surgery until the day before the operation, waiting until after I had already traveled across the country, and contradicting the recommendation of my in network doctor.
I also found out that since I didn’t have the PacifiCare insurance for 18 months, all other insurers could deny me coverage for having a preexisting condition. Now I am impossible to insure. Brokers tell me I’ll “never be covered.”
I have paid out of pocket for lung and abdomen scans and I’m supposed to have them every six months—for life. Together, they are $1,000 each time. I still have to figure out how to deal with $25,000 I owe my parents for a loan they gave me to partially pay for the $60,000 surgery that PacifiCare denied. I don’t know what the future will hold. I’m self-employed, and still not working as much as before all this.
The only good thing about this story is that my Dad saved my life. My chances of survival are much better with the early detection. For that I’m grateful. The question now is how can I afford to stay healthy.