Pre-existing conditions.

[Blue_true]

I talked to a person today by chance. The person had surgery to resolve a life threatening condition. I noticed medical aids the person was still using and had to ask questions about what happened.
I was told what happened, but it is what I was told next that blew my mind. Surgery to correct the condition cost the person several hundred thousand dollars. The person seemed psyched out because the insurance policy that the person maintained for seven years is refusing to pay any of the cost, even for medicine and physical therapy, ZERO, nothing at all.
Even if the person had a shitty, high deductible policy that President Obama warned about, the out of pocket for the type of surgery seems high (brain surgery to relieve pressure on the brain and fusing of a disk in the spine). Maybe the Doctors on DU can give an idea of how much such surgery cost, but from what I understood it cost $200-300 thousand dollars and the insurance company is refusing to pay a dime, citing pre-existing conditions because the person had a spinal injury in an automobile accident that existed before the policy was purchased.

Any thoughts?

I suggested that the person call a law office that sues insurance companies, but with Trump in office and republicans rolling back consumer protections, trying to repeal Obamacare and stacking the Courts with incompetent rightwing stooges, I am not optimistic.

BTW, hearing the person's story is why I want to rip the throats out of the "no difference" idiots and the Bernie or busters. What is happening to that person can happen to any middleclass or poor person who doesn't have a free few hundred thousand dollars sitting around.

[LuckyCharms]

1. Normally, the hospital will get pre-approval from the

insurance company before a procedure like this.

It's hard to tell exactly what happened here.

[Blue_true]

4. As best that I could figure out, the person had something like an anuresym.

I don't know the person obviously, but from what I was told, I surmised that the situation was life or death at the moment of the decision on surgery. I was told that the surgery was long, didn't ask how long because I was a bit upset about the insurance company conduct. Even if the surgery should have been ore approved, does it not being pre approved invalidate payment of costs for medicine and physical therapy?

[LuckyCharms]

9. This is typical insurance company bullshit.

ANY time they can dispute charges, they will dispute. They are such fucking assholes. Sorry for the language, but this is my hot button.

What will happen is the patient will not be able to pay, so the hospital and doctor will just go in circles with the insurance company until they get some money. They will also try to get whatever they can from the patient if the insurance won't pay. The hospital will also end up writing off a ton of the cost.

The medicine and physical therapy part of this is much more problematic. This is why we need single payer.

[Blue_true]

12. I am ok with single payer. Anyone who is a citizen get treated without bullshit.

We can have options so that non citizens can get critical and preventative care, it is best for the system overall to have such options in place.

[politicaljunkie41910]

14. The Affordable Care Act is still the law of the land and has not been repealed so assuming as you

say he had insurance, he should be covered. However I don't think it does anyone any good to speculate without all the facts. I have very good health care coverage and have been seen many times in the past couple of years. Recently I received a large bill in the mail which I was not expecting. A quick phone call determined that the billing information was not coded correctly. They apologized and the problem was taken care of. I'm not saying that a mistake is what happened in the situation you described, but I do hear things from time to time, things that are so awful and that information later turns out to be inaccurate. If the person you speak of had insurance it's turns should be dictated by the ACA. Granted, under the ACA there were Gold, Silver and Bronze plans which would dictate how much of the costs the Patient is responsible for, but it eliminated insurance companies playing bullshit games as it relates to pre-existing conditions.

[Ohiogal]

2. You are so right

And it makes me furious, too, when people are apathetic or assume both sides are equally corrupt.

I am so sorry about your friend's circumstances. Countries like France, Australia, Canada, must think we are total idiots when it comes to health care. I wish I could shout out to the world that the majority of people in the USA are NOT stupid, selfish, conservatives.

[Blue_true]

5. The person isn't a friend. A stranger actually. But what happened is really sad and enraging. nt

[Takket]

3. something isn't right.........

a surgery like that doesn't get scheduled and done until the patient/hospital/insurance company have all approvals in place. There is no way that could have happened without prior approval. Tenn your friend to ask the hospital who contacted the insurance company and what approvals were obtained.

[Blue_true]

6. The person is not a friend.

I suggested contacting an attorney and let them advise.

[LuckyCharms]

11. Sounds like it was an emergency surgery. n/t

[Ms. Toad]

7. If the surgery happened before the ACA

the policy could well have had an exclusion for all treatment related to the condition. Typically you were just rejected for insurance entirely, but a few companies issued coverage but excluded treatment for any conditions that were pre-existing. Other policies had a maximum out-of-pocket. Once you hit that, the company was not under any obligation to pay more.

If the policy issued after the ACA, and it is a compliant policy, the care was provided within the terms of the policy, it should be covered at some rate (there might be a large (~$10,000) out of pocket payment required before insurance kicked in - but medically necessary treatment after that would be covered.

(It could have been a grandfathered policy, or it could be short-term insurance - both of which are choices (at least nominally), and are not required to be compliant)

You don't have enough details to really get a picture of what is going on.

[Blue_true]

8. I don't know the person, but was told the policy is post ACA.

I live in Florida, an anti-ACA state, so I have no idea what was in the policy relative to lifetime caps.

Even if the policy is ACA compliant, it seem to me that with Trump in office and attacks on the ACA, insurance companies can bet that they can refuse proper payment and go to Court and win there with the judges being put in place. Maybe I am being conspiracy minded.

[kag]

10. What state is this?

I'm just curious because my brother used to work for a VERY good attorney who handles cases like this one.

He lives in Dallas. Let me know if you'd like some info about him. (You can pm me if you want.)

Either way, I hope things work out for this person. It's hard enough to go through something like that without having to worry about paying for it. (Just like the bad old days before Obamacare.)

[Blue_true]

13. Florida. There are plenty of Attornies here that sue insurance companies. nt

[pnwmom]

15. The ACA says that all policies, whether group or individual, have to cover the Essential Benefits,

including hospitalization and surgery -- without regard to preexisting conditions.

So unless this person somehow has an old junk policy, and never signed up for Obamacare, his policy has to cover the surgery. If he doesn't have a group policy, and just decided to pay a penalty instead of buying an Obamacare policy, then that's the choice he made.

I bet he has an old junk policy and was one of those who decided not to get a policy on the exchange.

Here is a state insurance hotline for Floridians:

https://www.floir.com/Office/SearchableTools.aspx