An open letter to the leaders of health insurance companies and our legislators
October 11, 2009 (click HERE for an addendum added 7/2/11)
In case you were looking for convincing arguments that our health insurance system is in serious need of reform, here are just a few of my own recent experiences.
I am a relatively healthy 55 year old male who proactively watches and manages his health. Since I am no longer employed, I recently needed to find private health insurance so that I can continue getting medical attention if and when I need it.
The first health insurance company I applied to denied me coverage because of a “pre-existing condition.” What was the pre-existing condition? Despite being in a desired weight range, playing tennis twice a week for 15 years, and three years of going to the gym for 70 minutes of cardiovascular exercises five days a week, I had been recently diagnosed with mild hypertension (high blood pressure). For this inherited condition (which had not responded to exercise and changes in diet), my doctor prescribed a low dosage generic blood pressure medication which had my hypertension perfectly managed to a very healthy range. My reward for actively managing a condition many people ignore: Company #1 denied me health insurance coverage.
It turns out I also have a condition called BPH (benign prostatic hyperplasia). This is a non-cancerous growth of the prostate that – according to reliable medical sources – affects over half of men over the age of 50. Although I did not want treatment for this non-threatening condition, I was convinced that my personal doctor should know everything about my medical state. So I told my doctor about this condition, and it was duly noted in my medical records. My reward for keeping my doctor completely informed about my health? The same insurance company that denied me coverage because of my controlled hypertension stated that even if they had not denied me coverage, they would have excluded BPH and any symptoms or worsening from my coverage.
Still in search of private health insurance, I applied to a second large health insurer. Like Company #1, this company also pulled my medical records. Unlike Company #1, they were happy to issue me a health insurance policy; however, they noticed that I had paid visits to a dermatologist over the past several years, and said they would exclude any coverage for my skin or related conditions from my medical coverage. The reason I visit a dermatologist annually is that I grew up in the Phoenix metro area, and many years of exposure to the sun can damage the skin. By visiting my dermatologist regularly, I can have sun-damaged portions of my skin treated while they are still benign – BEFORE they turn into cancer. But this proactive medical attention resulted in Company #2 denying me coverage for the largest organ in the human body.
Again, still in search of medical coverage, I applied to a third company. This company, who had access to the same medical information as the other two, was willing to underwrite me (with no exceptions like the prior companies). That is, until we ran into a snag. A question that appears on virtually all medical insurance questionnaires is “have you ever been denied coverage?” For no other reason but that Company #1 had denied me coverage several weeks ago, I was now in danger of being denied coverage by Company #3. As it turns out, I was able to have my doctor send a letter to Company #3 that convinced them the original denial of coverage was unfounded. And I finally had health insurance.
Now I finally had private health insurance coverage, so I figured my problems were pretty much over.
Not so fast! Continuing my proactive efforts to manage my health, I visited my doctor for my annual physical. (Despite the fact that my private health insurance is a high-deductible policy, it pays about $250 each year for an annual physical.) During this routine annual exam, my doctor noted that I had not had a tetanus shot in over 10 years, and he recommended I get one while I am in the office. I accepted this offer, and the bill my doctor presented to Company #3 included a $60 charge for the tetanus shot.
The charge for the tetanus shot is denied. Let me be clear. The insurance company didn’t say “We will cover the shot, but it is subject to your annual deductible.” The insurance company says “Adult immunizations are not covered under your plan. WE DO NOT PAY FOR TETANUS SHOTS FOR ADULTS.” (Note that for items covered under health insurance plans, reimbursement typically is less than half of the billed rate. This means Company #3 – if they HAD paid for the shot, probably would have paid less than $30.)
I was curious about my insurance company’s wisdom in denying coverage for a tetanus shot. I went to several reputable medical web sites, including www.mayoclinic.com and found the following information on tetanus:
Regarding prevention, the Mayo Clinic writes “You can easily prevent tetanus by being immunized against the toxin. Almost all cases of tetanus occur in people who've never been immunized or who haven't had a tetanus booster shot within the preceding 10 years.”
Regarding treatment, the Mayo Clinic writes “Tetanus infection often requires a long period of treatment in an intensive care setting. … [S]ome people have lasting effects, such as brain damage…. Tetanus may be fatal despite treatment.” In addition, the US Government’s Center for Disease Control web site states “2 out of every 10 people who get tetanus die from it.”
If I die from tetanus, the insurance company could avoid paying future medical costs, but the other costs, such as the time in ICU, the drugs, and the respirator, would apparently all be covered by the insurance (after I paid my large annual deductible). According to a study available on the web site of the National Institutes of Health, in 2002 the typical cost of being on a respirator in intensive care was about $2,000 per day – I can only imagine what that cost would be today.
I personally don’t think it makes sense for a health insurance company to deny a $30 charge for a tetanus shot (which would have been subject to my deductible, anyway!) when such an action might make the company subject to paying $2,000+ per day and (although the insurance company might not care) risks my life.
Lessons health insurance companies are teaching
What lessons are the health insurance companies telling us with their actions, which include underwriting denials, exclusions of coverage, and denying coverage for immunizations?
· Do not get routine health care. If I had not been paying regular preventative care visits to my doctor, my hypertension would have been undiagnosed and I would have been issued coverage by Company #1 – but of course I would have come to the company with undiagnosed risk factors!
· Do not tell your doctor everything about your health. I told my doctor about BPH – a non-life-threatening, benign medical condition common to most men over 50 – so that he could treat me with the most information available to him. As a result, Company #1 wanted to exclude this from any future coverage (even if it grows worse and eventually does threaten my health).
· Do not take proactive measures against preventable conditions. I paid regular visits to a dermatologist to prevent benign skin damage from becoming malignant. If I had not done this, I likely would have preventable active skin cancer today; but insurance company #2 would have written my insurance policy and had to treat me for cancer.
· Do not apply for health insurance. By applying to Company #1 and being denied coverage for a pre-existing but under-control condition, I almost became uninsurable by Company #3 who was otherwise willing to sell me health insurance.
· Do not get vaccines or inoculations for preventable diseases. Company #3 would rather let me die, or pay $30,000 for me to be on a ventilator in intensive care for several weeks, than pay $30 to inoculate me against a completely preventable but sometimes fatal disease.
Based on these experiences and much reading, I have concluded a few things:
This spring was the second anniversary of my health insurance coverage with Company #3. Anniversaries are the windows for changing coverage - or rather, for APPLYING to change coverage.
I wanted to "enhance" my health insurance coverage by adding coverage for prescription medications. My current plan did not cover prescriptions, which was OK because the two medications I take (for high cholesterol and blood pressure) are generic drugs available at Walmart for $10 per 90 day renewal. But I wanted to protect myself in case, sometime down the road, I am required to take an expensive medication. Company #3 offers an insurance plan which is virtually identical to my current plan, only it includes prescriptions - for a higher premium, of course. Because it's consider an "upgrade" to my existing plan, it is subject to underwriting; that's a fancy term that means "we get to look at you all over again and may deny you this coverage."
In fact, Company #3 did pull my medical history for this evaluation and did, in fact, DENY ME COVERAGE. Their reason for denying me the upgrade? According to them, I am now, according to my blood sugar readings "pre-diabetic." Interestingly, my blood sugar readings are steady, and essentially the same as they were in 2003, six years BEFORE Humana started selling me health insurance. My blood sugar was within the "normal" range for many years. However, on some date in 2005 (still four years before Humana underwrote me), the "normal range" for blood sugar was modified, and the high end of normal was reduced by 10 points, leaving my previously "normal" blood sugar rating now OUTSIDE the normal range (along with millions of other people with previously "normal" glucose levels).
Remember that my blood sugar was steady for the past nine years, but because of a change in the "standard" my blood sugar was slightly outside the range. It was still steady, and still slightly outside the range in 2009 when Company #3 decided it was OK for them to provide health insurance for me. But in 2011, this same steady blood sugar level was suddenly their excuse for denying me prescription coverage.
However, since they cannot drop me from my CURRENT plan (as long as I continue paying the premiums that have gone up about 16% per year), I continued on, covered by company #3 under my existing plan, but still without prescription coverage.
Let's imagine a hypothetical. Let's assume I in fact DO become diabetic, despite my attention to diet and exercise. And let's assume that the treatment for this kind of diabetes is a prescription medication which is not available in inexpensive generic form. And further, let's assume I cannot afford that medication and therefore my diabetes progresses untreated. According to www.mayoclinic.com, complications of untreated type 2 diabetes include: heart and blood vessel disease, nerve damage, kidney damage, eye damage, skin and mouth problems, osteoporosis, and Alzheimer's disease. Under my current insurance coverage, Company #3 would be obligated to cover the (non-prescriptions) costs of treating most of these complications, including doctor visits, hospitalization, tests and procedures - and all of these treatments would likely be far more expensive than the cost of the prescription medication that could have prevented these complications.
Thus, Company #3, by choosing NOT to cover me for prescription medications, has taken on the risk of paying for much more expensive doctor and hospital costs which could have been avoided by paying for the medication. By the way, under the plan I was trying to get, the prescription medication costs would still have been subject to the policy's $5000 annual deductible, so it's actually highly likely that the company would not have paid a penny for the prescription medication if I had the coverage.
Note also that if my untreated diabetes drives me into medical bankruptcy (responsible for 50% of all US bankruptcies prior to our recent economic downturn), I would be unable to pay my insurance premiums - in which case Company #3 could finally drop me from their rolls.
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