medical insurance questions (cancer)

Factual Questions
1

I have a friend who fears she may have breast cancer, who is out of work and does not currently have medical insurance. I have found local programs that can get her free treatment. She is afraid that once she is diagnossed she will not be able to get insurance down the road. She can buy a policy that will go into effect within a week. However we don’t know if they will try to say she has a pre-existing condition, because 5 years ago they found a lump under her arm pit, but a specialist said it was nothing but fatty tissue. We also don’t know what the insurance co’s ability to raise her rates are. What I would like to find out for her is:

how can she get coverage down the road if she does not get it now? could she get on a group policy through an employer? could she get medicare?

can the insurance co. deny her claims for having a pre-existing condition?

can they cancel the policy?

can they keep raising her rates on an individual policy? if so are their limits on this?

Thanks in advance to everyone who offers their informed advice on this thread.

2

A huge proportion of the answers to your questions will depend on where you are, as well as other factors, such as the specific wording of any insurance company questionnaire or the wording of any future insurance policy. So we’ll need more detail to give you good advice. However, if she lies about whether she’s been diagnosed with a preexisitng condition, I believe the plan could sue her down the road for fraud to get the money back from any claims they erroneously paid as a result of that fraud.

However, tell your friend that she isn’t necessarily doomed, even in the somewhat unlikely event that she is diagnosed with cancer. I once broke my leg 2 days before the insurance on my new job took effect. Believe me, this was no ordinary broken leg; in the 6 years since, it has required 4 surgeries, weeks in the hospital, various expensive rounds of imaging tests, countless hours pf physical therapy, numerous specialist visits…and although I had to pay for the 2 days’ worth of care until the policy kicked in, Illinois law required that my new employer’s insurance cover pre-existing conditions, PERIOD, if you were covered by other insurance wihtin the past 60 days. So aside from a few $10 co-pays, the rest of the medical care (which has probably totalled in the area of $100,000) has been essentially free.

3

If she has a pre-existing condition (which doesn’t have to be as serious as cancer) then getting an individual policy will be a problem. This does vary considerably from state-to-state. In some cases, pre-existing conditions are covered. Sometimes, you might have to wait a year or two. Sometimes pre-existing conditions are never covered. In some states, you can’t be denied insurance, but the premiums can be so high you might as well be (My husband was once quoted $1200 per month premium) That said, it never hurts to ask if you’re eligilbe for a particular policy.

It is much easier to get insurance, and to get coverage for a pre-existing condition, if you work for a large employer. Many small employers don’t offer insurance at all these days.

She can’t get Medicare until she is 65. However, she might qualify for the state program Medicaid.

That depends on the law where she lives.

If you lie on your application, you betcha. And they can sue you, too.

Yep, they can raise anybody’s rates. Maybe your state imposes a limit, maybe not.

Most likely, the “lump under arm” from years ago is totally unrelated to whatever is happening to her now, and really was just a “lump of fatty tissue”.

What’s the deal? If she has a lump in her breast she should have it checked out. Most of the time, it’s nothing serious. But if it’s cancer it needs to be treated.

If she hasn’t seen a doctor already, and she can buy insurance that takes effect quickly she can do so, wait for it to take effect, then go see a doctor. It should then be covered, since there was no prior diagnosis or record of the problem (whatever it is).

If she has seen a doctor and it has been diagnosed, then it’s a pre-existing condition.

If she has no insurance and is not likely to get any she still shouldn’t ignore it - there are charities and public funds to treat people who have no insurance and little money. I’m not going to kid you, it’s a tough thing to go through, but so is a serious, untreated medical condition.

4

While it is true that it depends on what state your friend is in, the best bet is to find an HMO ( I know it’s a dirty word!) But, if your friend becomes employed by a company that offers a fully insured HMO she cannot be denied coverage and her premium will be the same as everyone elses in the company no matter if they had pre-existing conditions or not. (At least this is the way it is in CT.)