My senior year of college I tore my labrum in my left shoulder. At the time I was covered under my parents’ insurance plan. While still under their plan, I had it surgically repaired and went through rehab. After the whole ordeal, I was told that my shoulder would actually be stronger than it was naturally. After graduation I ended up at a place where I was classified as an independent contractor, and thus ended up buying my own insurance. For the past 3 years my entire left shoulder hasn’t covered due to my surgery. As I understand it, even if I get shot with a bow and arrow in my shoulder, I will be paying out of pocket due to the preexisting damage.
Though I still pay for my own insurance, I know am now looking into possibly switching plans. I will be looking into a high deductible/health savings plan, and I plan on shopping around. I’m pretty confident that I can find a cheaper plan at a different insurance company. However, I would be willing to stay with my current one if they would cover my shoulder.
Does anyone have any experience bargaining with an insurance company? Will they care at all if they lose my business? Do I stand any chance of getting myself moved down a few “risk” notches on their actuarial tables (and into the realm of shoulder coverage) by arguing the health of my shoulder?
No, they don’t give a damn if they lose your business. No, you can’t argue your way into better rates or better coverage. You would be much better off joining a group plan if at all possible for a couple of reasons. Firstly, while they don’t care about losing your business they do care about losing the business of 50 or more people so your group does develop a bit of negotiating power. You are also much more likely to find a plan that waives the pre-exsisting condition clause if you have had coverage with no gap for the last 12 months or more. As an individual you really don’t have any pull and quite frankly if you call them more than once a month or so they probably want you to leave so they don’t have to deal with too much bullshit for a single life policy. Join a freelancer’s union or contractor’s union or something if need be but try to get on with a group plan if it is at all possible.
If group is out of the question, check out Golden Rule (they also operate under the name United Health One; they’re the individual division for United Health Care). Golden Rule will probably place an exclusionary rider on your shoulder, but they tend to write their riders VERY specifically so that a recurrence of the exact injury wouldn’t be covered but a different one would be.
You arguing your own case is fruitless. Having an agent argue your case for you is a different story and can, in some instances, work. You should go through an independent broker for your health insurance coverage anyway - it doesn’t cost any more and we tend to catch traps that consumers don’t. If you want, look up an independent agent in your state then PM me with the plans they recommend. Since I don’t have a dog in the fight (unless you’re in Georgia), I’ll tell you objectively whether or not you’re getting screwed.
The last time this was an issue with me, to be considered a “pre-existing condition”, the condition had to be something I’d received treatment for within the past six months. I don’t know if that was the rule with that particular company or if it was industry-wide. And this was with a policy I already had, not one that I was applying for.
But maybe that’s what you should do first – look at some policies and see how they define pre-existing condition.
it was my understanding that a ‘pre-existing condition’ applies only to conditions for which you rec’d treatment without the benefit of health insurance coverage.
if you had health coverage at the time of the ‘condition’, then it is not pre-existing and is eligible for coverage.
this is to preclude anyone from just running out and buying health insurance just because they decided that the bum shoulder that they’ve been paying out of pocket for, is just too much of a drag on their personal economy and they want someone else to pay for it…
i’m pulling all of this information pretty much out of my ass…but that makes it about 90% more reliable than anything else you’ll find on the internet…
We’re talking about an individual policy now - individual underwriting is very different from group underwriting. I’ve had clients who had surgery 2-5 years in the past run into problems with pre-existing exclusions.
This is not the case. Pre-existing conditions are any conditions that exist or have existed within the “look-back” period - usually five years, ten for some companies.
You’re thinking about “creditable coverage” - group plans can exclude any and all pre-existing conditions for a new enrollee for twelve months unless the enrollee had creditable coverage within 63 days of enrollment onto the group plan. If they had that creditable coverage, then the length of time they were covered counts towards that twelve month period. The concept of creditable coverage does not apply when a person is moving onto an individual plan.
I have rarely used insurance, even when I have it, but I’ve always wondered whether something genetic counted as a pre-existing condition. If you had, say, severe acne all your life, then decided to see a doctor about it…can they say 'Nope, sorry, this isn’t new?" I honestly have no idea.
All the definitions I’ve found say a time period must be stated for what constitutes a pre-existing condition…from six months to five years…some indefinite. But your policy information should list this somewhere. I think your first step is to ask your current insurance company for their definition…does it have to be something you have actually received treatment for within the stated prior period of time? Or as you seem to think, just something you have had happen in the past?I don’t have any experience with private insurance, having always had insurance through the military dependent system, or through my job, but I’ve always seen a stipulation that it be something you have been treated for during X period of time prior to the commencement of your current policy.
I will start by checking the language of the part of my policy that explains the exclusion of my shoulder. From memory, I think it essentially says, “…for the life of the policy.” Hopefully I’m wrong.
I agree it would be beneficial for me to speak with an agent about this. Unfortunately, my agent was a friend of my father’s who has since passed away. I will talk to my dad and try and track down what happened to the agent’s book of business.
As was mentioned above, it would be much better if I could get a policy with a rider that was very specific about my pre-existing condition (damaged cartilage) as opposed to the entire shoulder being excluded. It wouldn’t be ideal, but it would be better than what I’ve got now.
Joining a group would also be beneficial. I am not too optimistic about finding one, but I will research it.
(Mods, could you please fix the spelling of “pre-existing” in the title?)
Yup - I was born with a genetic disorder that does not really affect me in day-to-day life (two minor surgeries in the last 20 years), and most people would not know I have it since it doesn’t really affect anything. My case is mild - it can be much more serious.
However, it is an automatic decline for every insurance company… so much so that I had to leave the USA to get insurance (which was easy even after disclosing the condition).
I’d like to come back to the US, but doubt I’ll ever be able to… I have legal residency right now, but there have been years when I have had to move countries every 90 days to stay legal… eg 90 days in Turkey, 90 days in Germany, etc. That gets expensive, and prevents me from really owning anything that I can’t carry. Plus I am not allowed to work, so my only income is from an internet-based software company, and an ATM card from a bank I have not been to (because it is in the US) in 8 years.
Thus the “nomad” in my username… I figure I have lived in about 50 countries… only 4 of them with proper long-term visas, but I have never been illegal.
In the individual market, pre-existing conditions are defined as “conditions for which the proposed insured sought treatment within [the look-back period], or any condition that would have caused a reasonable person to seek treatment within [the look-back period].” The look-back period is the period of time before application that an insurance company will investigate and is usually five to ten years.
Something like acne would almost certainly not be considered a pre-existing condition unless the proposed insured had sought treatment or medical counsel.
I hadn’t sought treatment, but was asked by every insurance company if I had ever (since birth) be diagnosed with any condition. Thus I am an auto-decline for everyone back in the US. Here, my condition was deemed no problem as there is no rider on it
You’re right - you fell under that nebulous “would have caused a reasonable person to seek treatment” clause. Nominally, that exists to prevent people from breaking their arm, filling out an application, and getting checked out 30 days later when the app clears. Practically, it leads to people like you being declined. I’m not passing judgement on whether or not that’s a good or bad thing because I don’t want to be the guy who takes this informative thread in that Great Debates direction, but there you go.
Ah, ok, well…I haven’t ever been asked anything when signing up for insurance through the workplace. And that’s good, as psoriasis is genetic, and yes, a reasonable person would have done something long ago, but the lack of what are to me acceptable medical options makes me shrug. I just wondered in case anything I felt was an acceptable risk was suddenly discovered. Psoriasis got me nixed from the military, so I’ve always worried that insurance companies might see is as something a lot worse than it really is, too.
You’re right - group insurance (through the workplace) is subject to a totally different set of criteria when it comes to pre-existing conditions. Most policies hold the right to exclude conditions for 12 months subject to creditable coverage, but if the policy is big enough then they might not bother checking.
If you went to apply for individual coverage, it’d almost certainly be placed under an exclusionary rider (unless you’re in a state that doesn’t allow riders, in which case you’d be rated up). Psoriatic is an auto-decline in the individual market.
Bleh. Glad I just went decades without insurance rather than trying to be responsible and get it on my own, then. <Also glad I was just very, very lucky and never needed it>
In my case there is no treatment available - except occasionally I can get a a few benign tumors that I have had removed for cosmetic reasons… not that I am putting off needed surgery.
My wife is currently writing it… since she has been with me the entire time. We keep a log of how many days in each place since there are widely varying rules… eg 90 days out of every 180 is ok in most of Europe, 120 days in Tunisia, Turkey is good because it is a nice place to be and has many neighbors (pop into Georgia for 3 months, Syria for 15 days) etc.
My UK based insurance covers us everywhere except the USA… at t a cost of $200/mo.
I was in Sudan, UAE and India in Nov/Dec… tending to use UAE as a mild base. The one thing it does do is make tax filing complex. Some years I will have business receipts in 40 currencies.
