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Pre-existing conditions wiggle room?

Health ObamaCare Pre-existing Conditions 2010

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#1 Palisades


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Posted 30 March 2010 - 12:54 AM

Yves says HCR gives insurers wiggle room regarding pre-existing conditions because private insurers can still claim the person insured committed "fraud and intentional misrepresentation."



The way pre-existing conditions often come into play now is that a patient has an expensive ailment, and the insurer looks for a way to deny coverage. So they go through the patient’s medical history and find something, anything they failed to tell the insurer about, and use that as an excuse to deny coverage. And it doesn’t matter that the condition you failed to report was inconsequential, or that you failed to report it because your doctor diagnosed it late (for instance, you got Lyme disease before you got a policy, but no one diagnosed it until it was advanced Lyme disease, after you were covered).

Why can insurers use these weak excuses to cancel coverage? Because they have been able to argue successfully, that these omissions are “fraud and intentional mispresentation”.

Guess what? The draft bill preserved the “fraud and misrepresentation” out, and I have seen nothing to indicate that this language was revised. The executive director of a 150,000 member nursing organization, which opposed the bill, noted:


Insurers may continue to rescind policies for “fraud or intentional misrepresentation” – the main pretext insurance companies now use to cancel coverage.

So when will voters find out the full extent of the bait and switch? In 2014, when Obama hopes to have been voted in for his second term.

Can any lawyer types confirm this?

Edited by Palisade, 30 March 2010 - 12:59 AM.

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#2 JadziaDax


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Posted 30 March 2010 - 02:21 AM

Ugh, it won't be much of an improvement if this is true....they have to take the kid on, but not cover it?

They can't rescind coverage for pre-existing, but they can still not sell us the policy in the first place, and raise our premiums because of it? WTF?!!!!!!! I thought this bill was supposed to take care of that.

Please, someone tell WHY there is no public option......give me a serious reason why outside of "*whine*bitch*moan*TAXESSSSSSSSSSS*bitch*bitch*bitch*"....unless it really is the fault of the insurance lobby and the GOP buyout.

Edited by JadziaDax, 30 March 2010 - 02:23 AM.

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#3 BklnScott


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Posted 30 March 2010 - 09:07 AM

There was an episode of The Good Wife a few weeks ago that tackled this issue.  A wife wanted surgery on her fetus to correct a heart defect and the insurance company fought it tooth and nail, ultimately using data mining to discover a picture posted online of her husband smoking a cigarette on a drunken camping trip with his buddies.  

They connected that to a "no" answer on the smoking question on the application (it asked if he had smoked in the "previous six months") and used it as the pretext to cancel his policy.  And the judge upheld it, because the guy *did* lie, whether deliberately or because he just didn't recall.

I bet a lot of people lie on this question, incidentally.  

I think they call this practice "recission," and I can't see how you ban it.  It's an anti-fraud measure.  I don't know, but I doubt the Lyme's Disease hypothetical described above would pass muster, since the insured didn't know s/he had Lyme's at the tme she signed up.  You can't be held accountable for failing to disclose something you don't know about -- at least, I hope not.

There's no question that a) this law does a lot of good things (such as forbidding denial of coverage over preexisting conditions -- so don't commit fraud on your application!) *and* b) that insurance companies, being what they are, will try, and probably succeed, in finding ways to continue being d-bags.  Same as it ever was.  

But in this case, I don't see how you tell insurance companies, "you can't drop people even if you can demonstrate they lied on their applications."

BTW, in the episode, the young couple lost the case but ended up getting them to cover the surgery when the good guys' firm threatened to exposure the insurance company's sleazy, secret data mining operation which, IIRC, automatically investigated anyone diagnosed with serious conditions to see if there was a pretext to drop them.  Now, *that* sort of thing -- which absolutely happens in real life... there was a recent story about an insurer who did this for everyone on its rolls diagnosed with HIV --  I could see regulating.  It should be possible to achieve an ethical balance between preserving an insurer's right to do due diligence and forbidding them to cull their rolls with an eye on the bottom line and no thought of the well-being of the people whose healthcare they are responsible for providing.

Edited by BklnScott, 30 March 2010 - 09:21 AM.


There isn't enough mommy in the world to further a cause like yours!

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