BCBCS Must Think Your Breasts Are A "Pre-Existing Condition"

Marc’s girlfriend found some lumps in her breasts, the mammogram and ultrasound came back ok, but BCBS is denying coverage for the biopsy, saying it’s a “pre-existing condition.” The out-of-pocket cost is over $2,000. We’re confused, BCBS. What pre-existing condition? That she has breasts? That she might not have cancer?

The additional biopsy was recommended by the doctor because of Marc’s girlfriend’s family history of breast cancer.

Some helpful information for Marc: an insider once walked us through how to appeal an insurance company’s denial of care. Consumer Reports has a good appeal guide too.

Our health insurance system truly is sick.

Comments

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  1. Nick1693 says:

    =( Typical of most insurance companies.

    Like the new look, Consumerist!

  2. desertdust says:

    I thought my browser was broke.

  3. Angryrider says:

    Hahaha! Well this isn’t surprising. Yeast infections are pre-existing.
    Of course our health care system is effed up, but the American people seem unwilling to do anything about it.

  4. Murph1908 says:

    There’s got to be more of the story here.

    For example, was the existence of the lumps discovered before Marc’s girlfriend had coverage?

    If so, the company is right for denying the claim. The alternative is, everyone who discovers they have a lump or other possible serious health issue, and doesn’t have insurance, will sign up and expect to be paid.

    I don’t know this is the case, but opinions should be held back until more is known about this story.

    There is a LOT of information missing here.

  5. XopherMV says:

    I had an insurance deny a physical because of preexisting conditions. I talked with them and asked them what was my preexisting condition for my physical, the fact that I was alive? The physical is intended to find preexisting conditions. Their logic made absolutely no sense. That argument didn’t end up fixing my problem though.

    Yes, extend Medicare for all and put these health insurance companies out of business. Insurance adds no value whatsoever to our medical dollars. They are a complete waste of money that would be better spent on hospitals and doctors.

  6. GMFish says:

    Murph1908 “For example, was the existence of the lumps discovered before Marc’s girlfriend had coverage?”

    I think you’re missing the point. Both tests came back negative. Thus, there is no pre-existing condition as nothing has been shown to exist. How can there be a pre-existing condition if no condition exists?

  7. sir_eccles says:

    Life is pre-existing and death (along with taxes) is inevitable so must be pre-existing too!

  8. Murph1908 says:

    AND, the US has the best health care in the world. When cities were closing down for SARS, as close as Toronto, we were unaffected.

    The issue with our health care is the cost, which is amplified due to frivolous lawsuits and the burden of the uninsured.

    And anyone who thinks universal health care will solve any of that is fooling themselves. Somebody, a government official instead of an insurance executive, will need to make the hard decisions of who gets what treatment. Not every person can have every treatment. It’s financially impossible.

  9. chenry says:

    @GMFish: maybe the pre-existing condition is the lack of a condition.

  10. SuffolkHouse says:

    Idiots! Healthy breast are a pre-existing condition.

    This makes perfect sense to me.

  11. Murph1908 says:

    @GMFish:

    Just because she was wrong about it being cancer, it was still a pre-existing condition that caused her to go get it checked out.

    If I get dizzy spells, go get insurance to make sure I don’t have a brain tumor, get all sorts of tests done, then find out I was just dizzy, it’s still something that happened to me before I had insurance that caused me to go in for all the tests, even though there was no pathology to the symptom.

  12. SuffolkHouse says:

    @Murph1908:

    Bull. Nationaizing health care will make sure people who can’t afford health care will get it.

    People in Canada don’t complain about the health care situation.

    Countries with nationalized health care have more hardware and trained physicians for the maladies that plague the working and lower classes. Why? Because profit motive is removed.

    • frank64 says:

      @SuffolkHouse: I know many people from Canada who come to the US to go shopping. They can’t afford to buy things is Canada due to the taxes. It ends up costing the economy(everybody) anyway, it just means the costs and service isn’t directly related.

  13. Chairman-Meow says:

    You know all insurance companies mottos should be: “Deny first – backpedal later.”

  14. Nick1693 says:

    I just found a quote on archive.org from a while back (From The Consumerist.)

    “…Together we will storm the revolving doors of faceless corporations to call them naughty words for genitals, and they will begin to fear us. The Consumerist. Capitalism is broken. We’ll help you fix it.”

    I somehow think that fits nicely here.

  15. Anonymously says:

    @Murph1908: That makes sense.

    Denying coverage based upon “pre-existing conditions” is an important topic that people generally don’t understand, myself included. I think that if you’re in a group insurance plan (through your employer, for example), they can’t pull that on you, but I’m not sure. It’d be nice for the Consumerist to do an article or two on this topic.

  16. ModernDemagogue says:

    I could be wrong, but I thought its possible to test for a “breast cancer” gene, and that if you have that gene, a double mastectomy is often recommended.

    Moral and ethical debates aside, legally might that not qualify as a pre-existing condition?

  17. Daemon_of_Waffle says:

    Living is pre-existing condition, so coverage should be denied. We don’t actually want living people walking around, do we?

  18. snoop-blog says:

    Well this is a tough one. Based on the information we are provided (which isn’t much) we can only assume it was not a pre-existing condition.

  19. kennedy76 says:

    @Murph1908:

    Not that the US’s stellar free market health care system is anything to cling to, where 30 cents of every dollar spent goes to waste, 45 million people lack basic coverage and where life expectancy is 40th in the world (and lower than even Cuba’s), according to the Economist magazine (despite spending $2.1 trillion on health care in 2006, also according to the Economist).

    One other thing, in a study by researchers at the London School of Hygiene and Tropical Medicine looked at data from 19 countries for deaths of under 75-year-olds that should have been avoided with proper health care, the US came in dead last.

  20. ludwigk says:

    @Murph1908: Best healthcare in the world? Only for very narrow categories, such as elective surgery. On a global scale, according to the World Health Organization, the US ranks an abominable 37th place out of 50 developed nations that comprised the survey, between Costa Rica and Slovenia (two nations that I’ll wager 99% of American’s can’t find on a map).

    Seriously, did you think our healthcare was #1? I can’t imagine by what actual existing metrics you could come to such a conclusion. We do pay the more per citizen for our health care than any other country. Did you mean “most expensive health care in the world”?? We spend significantly more per person than France, which has the actual best health care in the world.

  21. Leiterfluid says:

    @Murph1908: She didn’t find lumps and then attempt to get insurance.

    She was insured, found lumps, and wanted to get them checked out. The insurance company refused to pay for the biopsy. Maybe you know this couple personally, but what I read indicated she was already insured. Her insurance company is just trying to get out of paying.

    States (not the federal government) need to enact laws that force the burden of proof on the insurance companies for non payment of services.

  22. tinycorkscrew says:

    If BCBS denied coverage because of a family history of breast cancer, they are in violation of the Genetic Nondiscrimination Act of 2008, and Marc’s girlfriend can sue the pants off them:

    [www.genome.gov]

  23. Shadowman615 says:

    @Murph1908: I don’t understand how it is you seem to know when she discovered an issue and when she got insurance.

  24. floraposte says:

    @Murph1908: I don’t think there has to be more, though. It’s possible that she was documented as finding lumps before she was insured, but it’s also possible that she wasn’t, which is why it isn’t in the story. There’s only stuff missing if it happened the way you’re hypothesizing.

    I got denied payment for a pre-existing condition once, for a knee injury. The pre-existing condition they claimed relevant had happened to the other knee. (*And* they charged the phone call to the doctor’s office to my home phone number, back when you could do that.) “Pre-existing condition” is like “usual and customary” in that the insurance company’s interpretation of the phrase won’t jibe with that in the dictionary.

  25. dante1337 says:

    lumps /= breasts. C’mon consumerists, haven’t you seen breasts before?

  26. dulcinea47 says:

    She was insured, found lumps, had two types of tests done and the dr. wanted a third test done, and the insurance co. said no. I can understand why they thought the third test was unnecessary, but maybe they should have said “We think this test is unnecessary” instead of “it’s a pre-existing condition”, which it wasn’t.

  27. snoop-blog says:

    So Ben, is marc someone you know because it’s not like you to not cite your source or put a link to the actual article. I’m going to assume maybe mark is a reader/commenter on here? Anyhow, there is a legitimate chance that it really was a pre-existing condition. People do commit insurance fraud unfortunately so…

  28. cashmerewhore says:

    @Greg P:

    It can happen with group insurance if they find out there was a lapse in coverage & you had the condition prior to that lapse in coverage.

    That’s my understanding atleast.

  29. snoop-blog says:

    Oh wait, so there saying that they aren’t paying for the tests, not the actual treatment for cancer? Well that is bull-shit then. Even if it was a pre-existing cancer, shouldn’t the tests still be covered?

  30. cashmerewhore says:

    @tinycorkscrew:

    We don’t know their reason for denying it as pre-existing. She could have fibrous growths/calcium deposits, and a history of them. These could be new lumps that are an overall pre-existing condition.

  31. KevinReyn says:

    My son was born with sever kidney issues which ultimately involved the loss of one of those kidney’s. As someone who had had to dance with multiple insurance companies I can shed a little light on this process. There are lots of causes to billing issues, insurance denials etc etc.

    When I get a EOB (explanation of benefits) I give it a quick smell test based on what my coverage at that time is. I look at the amount charged and if the amount I am responsible for is close (a few bucks) to the co-pay it never gets another look. However if its off by more then a little it gets full attention.

    I start with a call to the insurance company to clarify the reason for the denial. Once I understand why they did that I call the doctors office to discuss what the insurance company “thinks” was done with what was “actually” done. I say “thinks” and “actually” because all the insurance company has to go off is a procedure code. usually a 5 digit number like 22586. All it takes is someone to fat finger, transpose or generally screw it up to cause the problem. Usually a resubmition by the doctors office will help resolve this kind of error. Believe me these are more common then you would imagine.

    Now this is not to say the insurance companies hav some work to do to become more consumer friendly. In my case I have had Emprire BCBS and I will tell you they were one of the better companies I had the “fortune” of working with. Fortune I say because without the insurance my family would not have a house or food because I would still be paying off the 7 digits in medical fees I would have had to swallow.

    So bottom line is this knee jerk reactions to these kinds of things can get very emotional. Stop take a deep breath and walk the path. Usually the rep on the end of the phone if treated like a human being will try and help you.

  32. mythago says:

    @Murph1908: “frivolous lawsuits” have nothing to do with the cost of health care. If they did, malpractice insurance companies would lower their rates when lawsuits or jury awards drop. They don’t. I get that you applaud for-profit health insurance companies, but if you have to invent facts to support your position, either you’re a paid ILR lobbyist or you really need to re-think your position.

    @ModernDemagogue: No. You are thinking of underwriting – the insurance company’s deciding whether or not to insure you based on your risk, and the price at which they will sell you insurance. A family history of a disease you DO NOT HAVE is not a “pre-existing condition”. What “pre-existing condition” means is that you already have the condition prior to becoming insured.

  33. crackers says:

    When I was covered by Humana (Worst. Insurance. Ever.) they first denied my MRI’s for a pre-existing condition even though I had been covered by them for 2 years and had never had so much as an x-ray. When they discovered a tumor, they tried to deny coverage for ALL of my treatment. I fought with them for over a year before they decided to cover PART of my treatment. Thanks a lot for taking my money ($200/month!) and still leaving me with over $8000 to pay out of pocket. You’re the best, American Health Care!

  34. bobpence says:

    I and a colleague had insurance denied based on “pre-existing” conditions with our otherwise excellent group coverage. The reason: The insurance company assumed we had not been covered for the six months prior to getting coverage with them (I had in fact been paying $600 per month COBRA up to and, by a few days, overlapping my new coverage!). They wanted to wait six months before covering his wife’s maintainence scripts.

    The solution was the “confirmation of coverage” letter I got automatically from the old insurer. It said I ‘may be asked for it’; I was never asked for it, I had to force-feed it to the new insurer.

  35. samurailynn says:

    Not having cancer is definitely a pre-existing condition. Did she not have cancer before she had this health insurance? See, see! Pre-existing not cancer!
    /sarcasm

    Health insurance needs change.

  36. HIV 2 Elway says:

    @ludwigk:
    France, which has the actual best health care in the world.
    How are you defining “best”? Longest life expectancy? Cheapest? Access to? Cutting edge treatments? Asinine rankings?

  37. mythago says:

    @KevinReyn: nobody is claiming it’s OK to be rude to the customer reps. But if you really believe it’s all a matter of fat-fingering, you’re incorrect. Insurance companies increasingly take the approach that the DEFAULT is to deny care, and pay reluctantly only if you fight them. I have had an insurance CSR flat-out admit that her company, Aetna, deliberately understaffed its phone lines to discourage customers. (This is the same company that required a doctor to fill out a form confirming that chemotherapy was not an “elective procedure”.)

  38. Jevia says:

    @Murph1908: Health insurance costs are high because more than 1/3 is used for the administrative process that denies more claims than it approves. If the claims weren’t denied, premiums would go down and everyone would have more healthcare (or more people would have healthcare).

  39. timmus says:

    I really wish all of us who are against for-profit health had some way of organizing. There have to be tens of thousands of us spread across many different websites, and if we all were able to do something instead of bitch about it online, there would be some real change in US healthcare.

  40. tinycorkscrew says:

    @cashmerewhore: We don’t know why they denied coverage, thus I began my sentence with “if.”

    However, we do know that her doctor recommended the biopsy because of her family history.

  41. SuffolkHouse says:

    @ModernDemagogue:

    I’m quite positive that if you have a genetic predisposition to breast cancer, that predisposition is a pre-existing condition.

    I’m afraid coverage would have to be denied in order to maintain the holy integrity of free-markets.

  42. tinycorkscrew says:

    @SuffolkHouse: As stated in an earlier post, denying coverage because of genetic predisposition violates federal law.

  43. jswilson64 says:

    @Murph1908:I agree – let’s see a timeline here, when did coverage start, when was the exam, etc.

    Also, which BCBS licensee are we dissing here? There are several (dozens?) around the country. Blue Cross Blue Shield is a brand, not a company.

  44. Angryrider says:

    You know, that list of denying health care for pre-existing conditions is pretty long. Wraps around and entire house and more even.
    US does have the best health care, provided you are rich and VERY healthy, with no chance of illness or disease.

  45. ZoeSchizzel says:

    Our son will go off of our health insurance at the end of August when he turns 22. Any suggestions on companies I should look at or avoid to buy an inexpensive policy for a healthy kid?

    Also..it always kills me when people point out that Canadians have to WAIT for their medical care! DH and I have primo insurance (that you taxpayers subsudize because he’s a government employee) and there have been many times when we’ve been given appointments well into the future (and in MONTHS) even for conditions that you’d think would rate expediency. Nah. No one’s in a hurry, not even in the ER. I can’t speak to the overall competency of the Canadian system, but don’t haul out the “you gotta wait” arguement when arguing against a government run health system.

  46. jswilson64 says:

    @snoop-blog: Oh, so you got a copy of Marc’s Girlfriend’s plan booklet? How do you know what is and isn’t supposed to be covered?

  47. mythago says:

    @jswilson64: even better, how about you READ THE POST? Coverage is being denied not for the mammogram and exam, but for the biopsy her doctor recommended, based on a “pre-existing condition”. Either BCBS is pretending family history = pre-existing condition, or they are pretending that a biopsy is never covered because the whole point of a biopsy is to determine if what you have is malignant.

  48. snoop-blog says:

    @mythago: It’s best to not feed the trolls. :)

  49. floraposte says:

    @snoop-blog: Even if she had detected an irregularity prior to her coverage, I don’t see why a doctor-recommended biopsy would be “insurance fraud.”

  50. snoop-blog says:

    @floraposte: Yeah I was confused by the way I read it. But you’d be surprised how many doctors lie to insurance companies everyday.

  51. jessicat says:

    Why am I not surprised by this? I had BCBS when my son was born and they denied the claim for my emergency C-section as I didn’t call in advance to inform them of the surgery.
    After I explained that I was too preoccupied with having a living person yanked out of me to give them a ring, they paid the claim.

    At this rate you’d better get insurance the second you’re born so as not to get a “pre-existing condition” denial.

  52. mythago says:

    @snoop-blog: Oh, I know it won’t make a difference to the trolls, but sometimes normal people are misled by them. Third-party arguing :)

  53. lilliangrey says:

    I had also very recently found lumps in breast, so this information may help. I live in Illinois and so I will be referencing Illinois law and policies, but perhaps Marc’s partner may find similar laws in her state. I spoke with a lawyer friend of mine and he unearthed some insurance statues for me.

    “The Illinois Insurance Code, 215 ILCS 5/356n, limits the circumstances in which an insurer can include a specific policy term that excludes coverage for, fibrocystic conditions.

    (215 ILCS 5/356n) (from Ch. 73, par. 968n)
    Sec. 356n. Fibrocystic condition; denial of coverage. No group or individual policy of accident or health insurance or any renewal thereof shall be denied by the insurer, nor shall any policy contain any exception or exclusion of benefits, solely because the insured has been diagnosed as having a fibrocystic breast condition, unless the condition is diagnosed by a breast biopsy that demonstrates an increased disposition to the development of breast cancer or unless the insured’s medical history confirms a chronic, relapsing, symptomatic breast condition.”
    (Source: P.A. 87-519; 87-895; 87-1066.)

    What we have taken this to mean is that there are special provisions regarding breast cancer that limit insurance companies from excluding coverage based on breast cancer alone, regardless of family history.

    To find out state-by-state rules on this, I visited http://www.nahu.org/consumer/healthcare/topic.cfm?catID=22&state=IL

    Good luck. I’m glad she’s negative for cancer.

  54. Yurei says:

    @Murph1908:

    “The issue with our health care is the cost, which is amplified due to frivolous lawsuits and the burden of the uninsured.”

    Well excuuuuuse me for not having health insurance, but it’s not exactly affordable nor easy to get. Most of the available work around where I live right now (and I am constantly searching) is part time only. Employers only want to hire you at part time so they do not have to provide benefits to you, or sooner as if they did for full time people. And even then if you do eventually qualify for insurance after working there between 6 months and a couple of years, it’s garbage. complete, utter garbage that covers nothing but emergency room visits, if you’re lucky.

    Working three part time jobs to try and earn better than federal minimum wage and just in general, survive is horrid to try and get health insurance on. I can buy insurance through some companies who are not my employer, since my current employer does not offer it, but it will cost me at least 2 and a half weeks’ pay. Which is totally not realistic when I have to pay utilities, food, gas and car maintenance, car insurance, etc. It is sad that my car gets to be insured, but not me. But if my car gets wrecked, i’m in deep trouble because then there goes my livelihood. It’s not like I get the option of public transit, either.

    I don’t see where we, the uninsured are such a “burden” on everyone else. Maybe in other states, but not in NH. Nowhere is the government offering to help me meet even the most basic needs of my existence, i’m all on my own for that. I suffered last year for over a month with an eye infection that would not go away and that was seriously hurting my vision, because I had absolutely no money to go see my doctor, and he wouldn’t write me a script over the phone for antibiotics without actually having me come in. And considering that doctors charge $100+ dollars just to come in and sit in their office and talk to them, I ain’t wasting my time and what little money I have to spare.

    So pardon me, I don’t see how we’re a burden since the government won’t even help us go get psychicals, or eye exams, or basic dental needs, or even help pay for papsmeres which is the only thing left I manage to go get done every year, and it breaks my budget to do it and as it is, i’m going to be unable to do it next year as they’ve started making extra mandatory tests with it at a high cost. I would really love to go get my vision checked out and my teeth cleaned and my dizzy spells looked into, but I can’t afford it.

    The system, good sir is broken. The government couldn’t give a rat’s arse about the people in general, and if I knew how to stand up and get them to do something, I would be on it in a heart beat. My boyfriend’s Canadian, and while their system isn’t perfect, it’s good enough. If you fall on the ice in winter and bust your leg, no worries. Not something I can say the same for here in the States.

  55. samurailynn says:

    @ZoeSchizzel: A lot of people dislike Kaiser Permanente, but I’ve had good experiences with them. They are also pretty cheap (comparably) for a young person. The best part to me is that you know up front what you have to pay, and since you are at a Kaiser facility, seeing a Kaiser doctor, you don’t usually get denied coverage. (I say usually because I’m sure there’s an exception out there.)

  56. thelushie says:

    @cashmerewhore: I was thinking Fybrocystic Breast Disease. In other words, lumpy breasts. It is a diagnosis and can be a real pain in the ass to have. Basically, cysts form in the breasts…multiple ones. My first mammogram (at 27 mind you) was a real nightmare because the little bastards don’t like to be squished.

    If I were her, I would get some more details. And I am happy all is well in the tatas area!

  57. samurailynn says:

    @Yurei: As far as a yearly pap smear – do you have a Planned Parenthood in your area? They provide that service and typically the fee is on a sliding scale, or you can sometimes get most of it covered if you’re very low income. I’ve used them before when I was in between jobs, or just barely getting by.

  58. Rectilinear Propagation says:

    I’m trying to figure out how the health insurance company would even know that the lumps were a pre-existing condition if that were the case. Seriously, how do they say, “You already had those lumps”? How would they even find out?

  59. AdvocatesDevil says:

    @ZoeSchizzel: Yep, this whole “well, elsewhere you have to WAIT for medical care” argument makes no sense. When the doctors said my mother needed some serious, invasive tests on her heart done within a week because they were so concerned about the results of the first round of tests, when do you think they were able to get her in? The next day? That same week? HA! It was 6 weeks later before they could squeeze her in. So the idea that you might have to wait for medical care doesn’t really worry me much. The idea that I’ll get a $40K bill because the insurance company decides to try to screw me when I’ve properly paid for full coverage… that’s worries me quite a bit!

  60. Murph1908 says:

    @Shadowman615:

    I don’t. That’s what I was saying in my original post.

    There seems to be a lot missing from the article.

  61. Tmoney02 says:

    Can the consumerist provide which BCBS this is. BCBS has many different branches (such as California, Florida, etc.) which operate independently from each other, and seem to be more or less strict depending on which one you have.

    Also info on if the woman told someone about the lumps before being covered would be helpful as well.

  62. Murph1908 says:

    @SuffolkHouse:
    From Wikipedia
    One of the major complaints about the Canadian health care system is waiting times, whether for a specialist, major elective surgery, such as hip replacement, or specialized treatments, such as radiation for breast cancer. Studies by the Commonwealth Fund found that 57% of Canadians reported waiting 4 weeks or more to see a specialist; 24% of Canadians waited 4 hours or more in the emergency room.

    On TV just last night was a story about how, gasp, waiting room times in the US are now at an hour.

  63. samurailynn says:

    @Murph1908: I’ve waited in an ER for 5+ hours… two days in a row.

  64. HIV 2 Elway says:

    @Murph1908: The hospital closest to me advertises ER waits under 30 minutes.

  65. HIV 2 Elway says:

    @samurailynn: Was it an emergency or would you have been better off at a non-urgent care center.

  66. Murph1908 says:

    @Jevia:

    And it’s going to be MORE EFFICIENT when the government, not concerned about profits, start running it? What percentage will then be eaten up by administrative costs?

    And your logic is flawed. You are saying paying for more procedures will be less expensive? You say that if they just quit looking at them and just paid them, it would cost less for everyone? If that were the case, I would imagine that they’d already be doing that.

    I am not employed in health care in any way, nor do I think our system is perfect. But no system is.

    What we should be focusing on is how to make health care more affordable for everyone. That way, the uninsured can get good treatment, and the insurance companies can provide their service for a lower cost and still make a profit.

    And profit is good. It creates jobs and drives progress. Capitalism is what makes our standard of living what it is today. Now, go listen to your IPods.

  67. DrGirlfriend says:

    is the insurance company considering family history as a pre-existing condition? They shouldn’t be, but that’s the only thing I can think of.

    The other thing is that I have found several BCBS states (their plans are by state) deny claims for random reasons, then it’s up to the provider or the patient to prove them wrong. I think that way, they hope to profit off of people who don’t appeal.

  68. HIV 2 Elway says:

    @Jevia: a 33% overhead rate is not uncommon in any industry.

  69. samurailynn says:

    @HIV 2 Elway Resurrected: This was at a time when I didn’t have insurance, and I tried calling about 20 different doctors in the area and was repeatedly told that there was absolutely no way I could be seen without insurance (not even if I walked in with cash in my hand). Someone finally told me that no doctor’s office would see me without insurance, but that if I went to an ER they couldn’t turn me away, and I could pay to see a doctor there.

  70. HIV 2 Elway says:

    @samurailynn: Bummer. Where I live we have non-urgent care units that are great. Its for stuff like bad poison ivy or a broken (but not urgent) broken bone, bad sprained ankle, etc. Thing that needs immediate care but isn’t on the same level as a heart attack or gun shot. Breaking the “emergencies” into two categories improves efficiency for everyone.

  71. Bye says:
  72. cordeliapotter says:

    @Murph1908: In America, I had to wait 4 months to see 1 specialist, 6.5 months for another, and 7 hours before I saw anyone in the ER. And my company pays Aetna $800/month just for me.

  73. mythago says:

    Guys, when somebody cites Wikipedia as evidence, we really can just move on.

    “How do you know that’s true?”

    “I just edited it into the article that says so!”

    @DrGirlfriend: Insurance companies used to make their profit by underwriting and sales; that is, they are supposed to make their profit by correctly predicting how much they may pay out in claims and setting pricing accordingly. Nothing wrong with that. The “claims” end of the business is NOT supposed to be the profit end of the business; once you are a customer, as long as your claim is not fraudulent, your insurance company keeps its end of the bargain.

    Eventually they figured out if they started jacking around on paying claims, they could profit that way, too. Never mind that you’re the *customer*.

    I have friends who work in insurance defense. You would not believe what insurance companies say about their customers or how much they really despise you and your uppity asking to actually be paid on the policy you bought.

  74. RandomZero says:

    @Murph1908: Exactly how is a city with a record of extreme panic (see also: when they deployed the troops for snow that wouldn’t have closed my high school) panicking at the municipal level reflect in ANY way on the health system? This is a straw man, plain and simple.

    For the record, we had it contained inside two weeks, and every case was traced back to one of the original carriers. Not charging for the privilege hardly makes this an inadequate response.

  75. Greasy Thumb Guzik says:

    @Murph1908:
    Several years ago, Consumer Reports wrote that the main reason there were long waits for specialists in Canada was that people wanted a specific doctor to treat them, but if they were a bit less choosy, there was little or no wait.

  76. katylostherart says:

    @Murph1908: the us has the best health coverage in the world IF YOU CAN AFFORD IT.

  77. katylostherart says:

    @samurailynn: yeah but then you go to the er and just signing in and waiting is a $900 bill.

  78. mythago says:

    @Greasy Thumb Guzik: When I lived in Canada, I was covered by their health insurance system – and the whole “waiting for years!” stuff was BS. I have longer wait times NOW that I did in Canada. Did you sometimes have a wait to see a specialist? Sure! Just like I do now in the US.

  79. chemmy says:

    I am supposed to get 2 annual breast exams as part of Guardian’s “Wellness” program…

    My last one was denied for the same reason – pre-existing condition.

    Still fighting that one…

    My guess was the same as yours – that my preexisting condition must be that I have breasts….

    And here I thought I was the only one.

  80. Katxyz says:

    @ModernDemagogue:

    It is possible to test for breast cancer genes. There are two genes associated with eventual breast cancer. The same genes are associated with ovarian cancer. Having them does not guarantee a woman will develop cancer, it just means her risk factor is higher, especially as she ages. Not having the genes doesn’t guarantee a woman won’t get cancer. Some women who have the gene and a family history of breast cancer do choose to get a preemptive mastectomy.

    I guess it could be a “preexisting” condition, but that sucks, since it only indicates a higher probability of cancer, not inevitable cancer. There are other genetic factors, like race, that are associated with certain types of cancer. I guess being a man could be a pre existing condition of testicular cancer, following the same logic (not your logic, but insurance company- no-morals please-logic).

  81. SexierThanJesus says:

    One day, people around here will realize the inherent clash of interests in a for-profit health system. I can’t help but wonder, though, how many people are just going against some sort of NHS because they don’t want to see healthcare given to those who aren’t “worthy”.

  82. pickscrape says:

    Health care is a basic human right.

    Anyone who says otherwise needs to go away for a while and think about it a bit. If you still can’t see that, please kindly leave the human race: you aren’t worthy.

    One upon a time the fire service in the UK was insurance based. If you didn’t have insurance, they didn’t stop your house from burning down. The house would have a badge or sign on it that the service would check for. If there wasn’t one, they would just drive away. Can you imagine that happening today?

    Presumably buying insurance while your house is burning would count as a pre-existing condition. A history of prior fires in your neighborhood would probably bump up your premiums considerably.

    Can you imagine the police service being provided by insurance? You are abducted, and the police refuse to help unless your family covers the costs themselves because you are not insured.

    Of course, being kidnapped is also a pre-existing condition. So would a history of prior kidnappings or burglaries etc. Moving would be a nightmare: you’d have to apply for police insurance and they’d want a full history of everything you’ve ever reported. Suddenly being a good citizen and reporting crimes becomes something people are afraid to do.

    I’m sorry, but this ‘profit is good’ argument is just tosh. While pre competition certainly works in some areas, it does not in this case. When the insurance company’s key responsibility is to their shareholders, it gives them the incentive to employ people who’s sole job is to dig for claim denial excuses. In other words, they are employed to kill people. Yes, it’s true. Think about it for a bit. It’s undeniable.

    There are many ways to measure how good a health service is. Mine is quantified by my first sentence: if the system does not see health as being a basic human right available equally to everyone, it sucks.

  83. golfinggiraffe says:

    @SuffolkHouse: That kinda depends. If hospitals were entirely government-run and the staff was all on government payroll, that may be true, but it’s not going to happen anytime soon either. If nationalized healthcare meant that the government would take care of all payments to hospitals that were privately/corporately run, then the profit motive is still there. My uncle is a doctor at Kaiser, and they have a weird organizational structure: one group is the HMO, another owns the facilities and administrative/functional, and another hires all of the medical staff. The medical staff portion is for profit.

  84. dragonfire81 says:

    I lived in Canada up until this year and how now emigrated to the U.S. My wife is American so she and I have talked a lot about healthcare.

    The Canadian system is NOT perfect and although some emergency room wait times are long, they are generally pretty quick with potentially life threatening situations.

    Case in point, I visited an Ontario ER in 2004 with chest pains. I was seen by a nurse immediately and by a doctor in less than 30 minutes. It turned out the pains were related to anxiety attack and nothing serious, but they occur right in the area of my chest where my heart is.

    The last two times I visited for non life threatening situations I have had to wait on average a couple of hours.

  85. @Murph1908: “There’s got to be more of the story here.”

    Not necessarily — I recently had a pregnancy test at my ob/gyn after missing my period for two months, and my insurance company wrote to me disputing the test, demanding to know “the nature and purpose of this test” and “the reasons for its administration.” (And, yes, the form they send said “PREGNANCY TEST” on it, not something random and unclear.)

    I called and they demanded to know why I had to have this test, and I said, “Repeated unprotected sex with my lawful husband.”

    No, not really, but I wanted to.

  86. cecilpl says:

    @pickscrape: Nominated for post of the year.

  87. TechnoDestructo says:

    I’m really surprised more health-care executives aren’t murdered. I mean you’re habitually screwing people over, many of whom are going to be imminently diseased. I’m sure a lot of them get real pissed off, and some of them would have the strength long enough to kill someone…and it isn’t like they’re worried about the consequences of it.

    I mean seriously, you’d think it would be a more dangerous job than being president or a taxi driver.

  88. ohiomensch says:

    I don’t understand how people can afford healthcare as it stands now. I am an HR rep and deal with our insurance company all the time on employees behalf.

    Stupid things like newborns being denied payment for inoculations that are mandated by the state, etc. We pay $46,000 a month to cover 38 employees and their families, and have been averaging 12 to 20% increases every year. There will be a time when most businesses will not be able to afford insurance for their employees.

  89. alysbrangwin says:

    @timmus: There’s a group of doctors that has been lobbying for it for a while. They lack the lobbying power of the behemoth AMA, though.

  90. legwork says:

    Mr. Popken, a star for @pickscrape, please.

  91. swimmey says:

    Even the AMA is coming around, and the American Cancer Society is getting positively militant on the issue.

    Most of the delays and denials (pre-existing condition, not in network, need more info, etc.) are merely ways to get out of paying what the inscos know are legitimate claims. They make you sit on hold, fax over paperwork, etc. while they work the float. When caught, they say “clerical error.” Myass.

    I worked with a woman who had a baby. Our beloved Cigna health plan decided the hospital was in-network for her, but out-of-network for the baby. That took months to straighten out.

  92. SuffolkHouse says:

    @Murph1908:

    Biggest complaints about the US health care system are about not getting it, or filing bankruptcy when you do.

    But you are right. A four hour wait sounds so very, very bad.

  93. 1983cowboy says:

    I was shopping for an individual family insurance plan a few years ago after a layoff, when I found reasonable prices with BCBS. Blue Cross would cover my kids (ages 16,14 & 10)and me, but would not cover my wife at all. Her pre-existing condition was the fact that she had given birth. Man, she had some nerve, huh? Take good care of herself for 30-plus years; then go out and endanger her health and Blue Cross profits by daring to launch into a textbook, trouble-free pregnancy.

  94. Yurei says:

    @samurailynn: Unfortunately, going by their website the nearest one that does paps is 40 minutes away, too far to drive on a strapped budget with current gas prices :( Although by the time March comes around, maybe a miracle will happen and gas will drop to $2 and then I could afford to go. I heard something briefly just a couple months ago (after I got mine already done for the year, naturally -_-) that a local hospital is having free ones if you have no insurance and aren’t eligible to be on anyone else’s. My only problem is, I am very reliant on my prescription for apri that my current OBGYN writes for me, I have horribly, horribly strong menstrual cramps that leave me bedridden for about 3 days without it, and thus I lose a lot of money by not being able to work and get in trouble at work. So my worry is if I manage to find somewhere else reasonable to go, will I be able to get my ‘script for the year. My regular physician, who I haven’t seen in years does paps I know, but he still prob charges a fair amount and well, a strange man down there= not cool.

  95. Indecent says:

    My fiance had his first ever kidney stone. Not knowing what it was, we took him to the hospital.
    His insurance (Medical Mutual) called it a pre-existing condition, and a 4 week showdown ensued until they resubmitted and processed it – and he’s one of the lucky ones.

  96. jswilson64 says:

    @mythago:
    Even betterer yet, how’s about you read the post I replied to. Quoth snoop-blog: “Oh wait, so there saying that they aren’t paying for the tests, not the actual treatment for cancer? Well that is bull-shit then. Even if it was a pre-existing cancer, shouldn’t the tests still be covered?”

    How does he know what’s covered under Marc’s girlfriend’s health insurance? Maybe you hadn’t heard, but all insurances plans aren’t created equal, and some don’t cover stuff that you’d expect “should” be covered.

  97. Brunette Bookworm says:

    @ModernDemagogue: Possibly, however didn’t Congress just pass something about not being able to deny employment or insurance because of genetic testing results?

    UMmm, here is article on it…
    [www.iht.com]

    Anyway, they could argue it but carrying the gene does not mean you have cancer or that you will ever get it, just that you are more likely to.

  98. Brunette Bookworm says:

    @Murph1908: And plenty of people in the US wait hours and hours in an Emergency Room as well.

  99. @pickscrape: Ah yes, the “Fire Markers”. The agency I work at has a small collection of those markers – domestic and international.

    It’s unreal to me, the idea of fire departments only responding to certain homes based on the fire marker. But, many years ago, that’s how it went.

  100. Jackasimov says:

    I owe 15k+ on a surgery that BCBS said they would cover – then decided afterward they’d rather not. Remind me to tell you the story sometime. It’s completely sick.

  101. Chiefaholic says:

    The reason the government can provide healthcare more efficiently is that under a single-payer system, administrative fees are drastically reduced. The amount of money spent by physicians and insurance companies who have to submit mounds of paperwork for approval of each procedure, research into a patients medical history, etc. is astounding.

    The other proven effective cost reducer under a government health system is the ability for EVERYONE to receive preventative care at no cost. Many conditions can be treated cheaply and effectively if caught early, but if you can’t afford the preventative care, you end up paying many times more in the long run. Government sponsored healthcare is the ONLY way to go.

  102. varro says:

    @Murph1908: U.S. health care best in the world? Hahahahaha.

    No doctors in Canada because the eeevil People’s Republic of Canuckistan pay doctors a few bucks more than a Tim Horton’s or Canadian Tire clerk? Well, guess what – there’s a shortage of primary care/general practice physicians in the United States, although not in doctors shooting people full of Botox.

  103. mokona7 says:

    So instead of denying a pre-existing condition, they denied the condition pre-existence?

  104. Ryan Paige says:

    Our insurance company initially denied the claim for my daughter’s birth, claiming her birth was a pre-existing condition.

  105. parabola101 says:

    The health care insurance in the USA is beyond the pale. BCBS refused to cover the anaesthesia for me during a major operation… what was i suppose to do??! bring a bottle of Jack and and some bullets???? And people are fighting against having a public option?