Those who qualify still face steep insurance premiums
By Getahn Ward • THE TENNESSEAN • November 13, 2009
No longer covered by his mother's health insurance after turning 25 two months ago, John Mathews has learned firsthand how difficult and expensive it can be to find coverage when insurers flag a past injury or illness as a pre-existing condition.
In fact, the majority of 10 insurance companies from which the Mathews family tried to buy a policy denied him coverage because they said two crushed vertebrae in his back caused by a 2008 car accident were a "pre-existing" condition that made him ineligible at any price.
One company was willing to sell Mathews a policy that included coverage of his back ailments for $1,200 a month; while another wanted to charge him $6,000 a year in premiums but exclude any problems linked to his old injury. That's far more expensive than the average $5,000 annual cost typically paid by a single person with employer-based coverage.
"We've been a healthy family and never had to deal with anything like this," said Jan Mathews, the young man's mother and a Brentwood resident who works for the state. "We've always been responsible and (he) can't get insurance?"
Mathews' plight and similar difficulties faced by many other consumers with medical conditions ranging from kidney disease to diabetes to high blood pressure come as the Obama administration pushes for a massive overhaul of the nation's health insurance system in Congress.
A landmark bill to extend health insurance to millions of additional Americans narrowly passed the U.S. House of Representatives last week and is pending in the Senate, where it faces more hurdles linked to costs, abortion rights and other issues. But it does include a ban on insurers using pre-existing conditions to deny coverage to anyone.
Some 36 percent of people who try to buy health insurance on their own outside of group plans get turned down, face exclusions or are charged higher premiums because of pre-existing conditions, according to a 2007 survey by The Commonwealth Fund, a nonprofit research group.
That represents about 12.6 million people ages 19 to 64, the group said.
Consumer advocate Tony Garr, executive director of the Tennessee Health Care Campaign, says ending insurance denials related to pre-existing conditions remains a critical part of bringing affordable health insurance to the masses.
"That's inhumane and not fair because everybody is going to get sick at one point or another and that practice … needs to be outlawed," Garr said.
Bill would dilute risk
Pre-existing conditions for which BlueCross BlueShield of Tennessee, the state's largest health insurer, can deny coverage include cancer, diabetes, AIDS, cirrhosis of the liver, congestive heart failure, polycystic kidney disease and bipolar disorder. Asthma is among conditions that could be excluded but the coverage still can be written.
Under legislation being considered in Congress, insurers won't be allowed to use health status or specific health problems as a basis for setting premiums. That should result in cheaper premiums for people such as Mathews, whose back condition resulted from a car accident that involved an insured motorist in Maryville, Tenn.
He was a student at the University of Tennessee in Knoxville at the time, his mother said.
Under one provision in the House version of health-care reform, a total of $5 billion would be set aside between 2010 and 2013 to help people who've been uninsured for at least six months, or denied a policy for pre-existing conditions, obtain coverage.
National insurers agreed to an end to their right to invoke pre-existing conditions as a way to block an individual's coverage in return for assurances that health-care reform would require all Americans to get health insurance by a set date. That expands the pool of risk and is a key to driving down insurance costs, proponents say.
Robert Zirkelbach, spokesman for the America's Health Insurance Plans trade group, considers the trade-off a fair one. "If you do market reforms, but don't require everybody to purchase insurance, there's a powerful incentive for people to wait until they're sick to purchase insurance," he said.
"We would love to do away with pre-existing conditions as long as everyone is in the pool," said Scott Wilson, a BlueCross BlueShield of Tennessee spokesman.
Agent is grateful
As an insurance agent in Columbia, Tenn., Cindi M. Nickle says she's grateful for her self-insured group policy even though she has to pay $700 a month in premiums and the first $2,500 of care before high-deductible coverage kicks in.
Nickle, whose mild case of Crohn's disease (an inflammation of the intestines) is a pre-existing condition, estimates that if she had to seek individual coverage outside of her group plan, no one else would cover her.
Last month, the insurers through which Nickle writes policies for others turned down two applicants seeking individual policies who had degenerative disc disease, a cause of lower back pain.
At times, a past surgery or some other medical situation that may have happened years ago can still count against an applicant as insurers comb through lab reports and other medical records.
Patsy Smiley, an Ashland City resident, said she's looking forward to turning 65 and getting on Medicare in February. She's paid a hefty price for health care and had trouble getting insurance coverage because she's taken the anti-depressant medication Prozac since 1990.
She pays $500 a month for a limited major medical policy today, and figures Medicare will provide better coverage at a lower price.
Or consider 31-year-old Kris Galbraith, who hasn't had insurance since his coverage under COBRA ran out three months ago. Insurers cited episodes of what they call "post-traumatic epilepsy" related to a pair of seizures he experienced two years ago in turning him down. His current job through a temporary employment agency doesn't provide insurance.
And then there's Debbie Heibert, a Brentwood resident once denied insurance because a set of lab tests suggested she could have had lupus, a chronic inflammatory disease, although later screening ruled it out.
Heibert and her husband, who owns a small business, have insurance but they pay more than $1,200 a month in premiums, with a $5,000 deductible.
"Health insurance is a huge mess for those who do not work for a large company," Heibert said. "It's sad it has gotten this way."
Previous PageGetahn Ward covers the business of health care. Reach him at 615-726-5968 or gward@tennessean.com.
