=( Typical of most insurance companies.

Like the new look, Consumerist!

I thought my browser was broke.

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.

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.

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.

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?

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

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.

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

Idiots! Healthy breast are a pre-existing condition.

This makes perfect sense to me.

@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.

@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.

You know all insurance companies mottos should be: "Deny first - backpedal later."

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.

@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.

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?

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

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.

@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.

@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.

@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.

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]

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

@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.

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

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.

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...

@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.

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?

@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.

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.

@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.

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!

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.

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.

@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?

@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".)

@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).

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.

@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.

@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.

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

@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.

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.

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.

@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?

@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.

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

@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."