Denial due to a pre-existing medical condition

Resources/Suggestions to research

Ø     A suggestion about insurance:  Since most insurance companies pay very poorly for myomectomy and hysteroscopic surgery, it is important to find a plan that has reasonable out of network benefits.  Otherwise a woman may get a great bargain on a hysterectomy she doesn't need.  Most of the MD's I know that contract with insurance do very little conservative treatment, since they are often reimbursed at less than the cost of providing the care.  So if someone is caught in an HMO, it may be impossible to get coverage for anything but a hysterectomy. - Dr. Indman

Ø      If you are denied health coverage because of any medical condition check with your State Department of Insurance about submitting a ‘Consumer Complaint Form’.   Keep a record of all the medical/insurance documentation and phone conversations in case the Insurance Department wants a copy.  

Ø      Medical Information Bureau (MIB) is a data bank of medical and non-medical information.  If you have been denied insurance it may be a good idea to check with the MIB to make sure any information they have about you is correct.  To contact the MIB:  Mailing address is Medical Information Bureau, P.O. Box 105, Essex Station, Boston, MA  02112, phone  (617)-426-3660, or their web site mib.com.  

Ø    When purchasing health insurance, most individual health insurance policies are sold through agents.  Contact at least five agents for quotes and information about the type of coverage in your area and their underwriting regulations.  Blue Cross plans and HMOs tend to have the best rates.  If you are a member of a union or association, ask if they offer insurance to their members.

Ø     When comparing insurance quotes create a question list and ask the same questions for each policy.  Write the answers down in the same order beside each quote so it will be easy to compare prices, insurance coverage, and out-of-pocket deductibles.  

Ø      Create a checklist of what benefits you want the health insurance plan to cover:

·        Hospital coverage - which hospitals participate in your area?

·        Surgery:  inpatient – outpatient – office surgery – surgery center

·        Office visits to a (participating) ‘in-network provider’ or (non-participating) ‘out-of-network provider’?

·        Does it cover specialist fees?

·        Office visit co-payment amount?

·        Is pregnancy, baby care, uterine fibroids, etc. covered?  What medical conditions are not covered?  What percentage is covered?

·        Mammograms

·        Are blood work, medical tests, ultrasound, x-rays, MRIs covered ‘in-network’ as well as ‘out-of-network’?

·        In-network doctors – check the list to see if your doctors are on it.

·        When does the coverage begin – waiting period? 

·        How much paperwork will you have to fill out each time you go to the doctor?

·        What are the monthly payments?

·        What is the deductible amount?

·        What is the lifetime amount of coverage?

·        Other (examples:  dental, eye, prescription):

·        Notes:  ____________________________

Ø     Ask your doctors what they think of certain health insurance plans.  The doctors have to deal with the insurance companies to get their fees paid.  They can tell you which health plans they participate in. 

Ø      Contact your State Department of Insurance to verify if an insurance plan is legitimate and what your rights are.  (Refer to the state you are a resident of below.) 

Ø      COBRA (Consolidated Omnibus Budget Reconciliation Act of 1996) (Federal)  If the company you left had 20 or more people, it must offer you insurance up to 18 months (if you meet certain requirements).  The individual would have to pay the insurance premiums.  U.S. Department of Labor brochure, "Health Benefits Under COBRA" contact U.S. Department of Labor at 1-800-998-7542 or 1-866-4 USA DOL.  Mailing address is Employee Benefits Security Administration, Atlanta Regional Office, 61 Forsyth Street, SW, Suite 7B54, Atlanta, GA  30303.

Ø     CAL-COBRA:  (California) There is a possibility that an individual could qualify for an additional 18 months of CAL-COBRA if they meet certain requirements, which would be a total of 36 months coverage.   

Ø     Mini-COBRA - (Florida) law provides similar continuation of coverage protection for employees who work for a company with fewer than 20 employees.  An employee must contact the insurer within 30 days of losing group eligibility, that he or she is eligible to continue coverage.

Ø      HIPAA (Health Insurance Portability and Accountability Act passed in 1996) (Federal) allows you to obtain group coverage from a new employer without having to satisfy a waiting period for pre-existing conditions.  One requirement is that you've had 12 months of 'creditable coverage' and haven't been uninsured for more than 63 days. 

Ø      NOTE:  For COBRA, CAL-COBRA, Mini-COBRA, and HIPAA ask for ALL the rules and regulations.

Question:  I have women contacting me who have been denied health insurance because of a pre-existing medical condition - uterine fibroids.   Do you have a health care program (High Risk Pool Plan) available for this situation?  (Refer to the state you reside in for the answer and/or contact information to this question.  Each state has different rules, regulations, and health plans for their residents. ) 

“I want to thank all the State Employees who e-mailed or called me with health insurance information for their state.” - Hope 

A "High Risk Pool" plan is to provide guaranteed access to health insurance.  It is a special program created by state legislatures to help people who have a pre-existing medical condition or who are considered uninsurable.

    States that have "High Risk Pools"

 (notated by * December 2003)
(updates notated by * 2005)

Information for Washington, D.C.

Other resources to research: 

Ø     A consumers guide to getting and keeping health insurance is available for all states at healthinsuranceinfo.net. 

Ø      National Association of State Comprehensive Health Insurance Plans (High Risk Pools) – naschip.org. 

Ø      National Association of Insurance Commissioners – naic.org.  

Ø    A Consumer Guide to Handling Disputes with Your Employer or Private Health Plan, 2005 Update.  The Kaiser Family Foundation and Consumers Union released an updated guide to help consumers through the process of resolving disputes with their health plans.