(David Mansdoerfer) – For my family, the month of May represents a stark reminder of the trials and tribulations we have gone through with the U.S. healthcare system. You see, my wife has been struggling with Lupus for nearly ten years. May, which is Lupus awareness month, represents the positives of the U.S. healthcare system – innovation, access to care, and emphasis on prevention.
Beyond the positives, however, lies the dark-side of our healthcare system – pre-existing condition clauses, rising costs, and information gaps. The dark-side, as I call it, puts a stranglehold on families similar to mine, who deal with pre-existing conditions.
In order to grasp a clear picture of what my family has had to deal with, I want to provide you with four scenarios that we have gone through.
1.After I quit my first job out of undergrad, in which my wife and I were on an amazing group health insurance policy, to go work as an independent contractor in the public policy world in Washington D.C., my wife and I tried to sign up for individual health insurance policy. After the initial application was done and processed, which took about two weeks, I got a phone call saying that ‘I’ was accepted and that my policy would go into effect at the beginning of the next month. Noting there reference to me in the singular, I inquired about my wife. To this, they stated that due to her pre-existing condition, Lupus, she was ineligible for the policy.
We went through this process with four other insurance companies before we finally found one to offer us a policy – even though that policy came with an extremely high deductible.
2.Shortly after moving to D.C., my wife came down with shingles, which is a common ailment to those with Lupus. For this, we went into the ER when it came to the point that she could hardly walk because of the pain. There, after we had been admitted, the hospital began to do a complete blood panel. The problem with this, however, is that we had just done a complete blood panel right before we moved to D.C. In that time, it was highly unlikely that anything had changed in her blood work.
Once I realized what they were doing, I tried to inform them that she had just had all of those tests done. By that point, however, it was too late. In the end, that hospital visit cost nearly $8,000 in out of pocket expenses for seven hours in the E.R. and to diagnose shingles.
3.Once I moved back to California to begin grad school at Pepperdine School of Public Policy in Malibu, my wife and I started contemplating when we wanted to get pregnant. Knowing that we did not have maternity care on our individual insurance policy, I called up my insurance company to see what it would take to add maternity on to our policy. They stated it would be very easy and all I would need to do is fill out a form and fax it back to them. Easy, I came to figure out, is a very loose term to insurance companies.
Another part of trying to add maternity onto our current health insurance plan required us to wait ten months and pay for the maternity coverage during that time. Yes, the insurance company wanted us to pay roughly $250 a month for ten months in order to even become eligible for maternity benefits.
Knowing that it was highly unlikely that another health insurance company would accept my wife, I begrudgingly sent my paperwork in accepting these terms. One month later, I called back in to check the status of my application. After being put on hold for a considerable amount of time, I was informed that our application could not be processed due to the fact that we lived outside of the state that we signed up in.
So, basically, we were told that we were out of luck on the individual insurance front.
4. After learning that we couldn’t sign up for maternity benefits via our individual insurance plan, we turned to our student health plan. This plan had everything that we needed – maternity benefits and a low deductible.
This plan, however, also had some issues. First, even though we would be accepted with no problem, we needed to come up with nearly $7,000 to cover the yearly premium. For my part of the health insurance, it cost about $1,500. For Megan, as a dependant, this plan would cost nearly $5,500.
Additionally, this plan also had a pre-existing condition clause which stated that pre-existing conditions would not be covered unless they had been covered continually for the last twelve months. (This would become important later)
After coming up with the $7,000 premium, everything was going great. Our maternity benefits were covered and we had a healthy growing fetus. Then, out of nowhere, we started getting denials on coverage from our insurance company. At first, they told us that the bills were most likely coded wrong and that they will reprocess.
A month later, after the bills were reprocessed, we got another round of denials. After calling in again, they informed us that, due to a pre-existing condition, we were no longer eligible to receive maternity benefits. So, after having maternity benefits for seven months, we were now left with nothing.
After going through the normal appeals process, and being denied again, I took things into my own hands. I filed a complaint with the California Insurance Commissioner and hired a lawyer a superb lawyer; James Azadian from the Enterprise Council Group.
Mr. Azadian was able to help us navigate the waters and understand what we were dealing with. We had been subject to after-market underwriting. In this, our insurance company had hired someone to come in and review our policy after we had already signed up for this plan. During this process, a determination was made to deny our benefits based on my wife’s Lupus and the date in which we were diagnosed pregnant, which came three days after our policy came into effect. Using this information, Mr. Azadian went to bat on our behalf and got our benefits restored.
Now that you understand what my family has been through, the next step is to detail how a market-based reform of the healthcare sector would be most beneficial to my family, and those like us.
There are four areas that market-based reform would benefit us.
1.Improve online medical information sharing. (In the second scenario, we would not have had to rerun multiple tests if they had been easily accessible online, thus, saving us money.)
2.Allow people to buy/change health insurance policies across state lines. (Even though we already had a health insurance plan, we were unable to change it because we moved to a different state.)
3.Encourage hospitals and doctors to make medical pricing available to the consumer. (The consumer should always know what the price of service is before making their choice.)
4.Simplify the legal terminology in health insurance plans so the consumer can understand it. (Time after time we got denied based on vague clauses in the language of our contract with the health insurance companies. The consumer should be able to understand their rights and what they are signing on for.)
Instead of trying to guarantee that everyone has health insurance in Obamacare, we should look to true market based reforms that help out families such as mine. We need reforms that lower cost and encourage competition.
Until these reforms happen, stories like ours will be all too common throughout the United States.
(David Mansdoerfer is the Director of Federal Affairs for Citizen Outreach)