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.
More From Consumerist
-
NY Attorney General Calls On Breast Cancer Charities To Be Transparent About Where The Money Is Going
-
Time For A Refresher: What Is Tare Weight & Why Should I Care About It?
-
American Airlines Apologizes To Mom Over Breast Pump Brouhaha
-
Wide Array Of Women's Health Care Costs Must Be Covered By New Insurance Plans As Of Today
-
There Is No Such Thing As A Free Breast Pump
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.
@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
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.
@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.
@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.)
@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!
@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.
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?
@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!
@Shadowman615:
I don’t. That’s what I was saying in my original post.
There seems to be a lot missing from the article.
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.
@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.
@Murph1908: I’ve waited in an ER for 5+ hours… two days in a row.
@Murph1908: The hospital closest to me advertises ER waits under 30 minutes.
@samurailynn: Was it an emergency or would you have been better off at a non-urgent care center.
@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.
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.
@Jevia: a 33% overhead rate is not uncommon in any industry.
@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.
@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.
@Murph1908:
CONTEXT:
[www.factcheck.org]
@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.
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.
@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.
@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.
@Murph1908: the us has the best health coverage in the world IF YOU CAN AFFORD IT.
@samurailynn: yeah but then you go to the er and just signing in and waiting is a $900 bill.
@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.
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.
@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).
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”.
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.
@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.
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.
@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.
@pickscrape: Nominated for post of the year.
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.
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.
@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.
Mr. Popken, a star for @pickscrape, please.
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.
@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.
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.
@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.
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.
@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.
@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.
@Murph1908: And plenty of people in the US wait hours and hours in an Emergency Room as well.
@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.
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.