Insurance Exclusion

[ChouDoufu]

I've just been approved for health insurance, but due to my recent AVR and
controlled high cholesterol, i have a 5-year moratorium. If no issues, then
after 5 years, cardio is covered. But.....and here's the rider:

************************************************************
" * Exclude Cardiovascular system, treatment thereof, causes and sequels

In all other aspects this policy remains unchanged. Please be reminded that any pre-existing conditions declared on your application form are subject to the terms of the Moratorium period.

This means that the member will have full cover provided they do not experience symptoms or seek medical advice/treatment for any of the pre-existing conditions declared and remain clear for a consecutive period of 2 years, or 5 years with any Cancer or Heart problems."
************************************************************

just to be clear on this, i asked for clarification of the meaning of "seek
medical advice/treatment." stupid question, i know, but i asked what is
the effect of ongoing treatment. i specified that this is 1) continue taking
statins to lower cholesterol, 2) regular blood tests to determine cholesterol
levels, and 3) annual echocardiograms to monitor heart condition.

the response is unbelievable! it appears that all three of the above are
considered seeking advice/treatment and will extend the moratorium
period indefinitely. which means i'm being offered insurance to cover
cardio issues after five years ONLY IF i refrain from taking prescribed
medications and doing routine tests.

i hope this is just a simple misunderstanding. i realize that this is a
british company, and as such, do not speak proper english. i have
requested clarification................

 

[catwoman]

And I suppose that other policyholders are covered for all routine CBCs, including cholesterol tests?

 

[ChouDoufu]

no, not coverage. all that stuff is excluded from coverage regardless. what they're
telling me is that cardio issues are excluded from coverage for 5-years. if nothing
happens during that period, my policy reverts to normal, and i would have cardio
coverage.

the question is what is the definition of "nothing happens?" they seem to include
normal testing as "stuff happens," and is considered an "event," in which case
the exclusion never ends.

so if i take my meds and get my tests regularly, i will never have cardio coverage.

but if i stop meds and never get another echo, they will give me coverage after five
years, at which time enough damage will be done that i could soon need that
cardio coverage!

this means, i'm being punished for doing the prudent thing.

 

[Duffey]

Is it possible to pay for the drugs and testing without notifying the insurance company? You move around enough that it seems probable that your records will be strung out over everywhere . . . .

 

[ChouDoufu]

Is it possible to pay for the drugs and testing without notifying the insurance company? You move around enough that it seems probable that your records will be strung out over everywhere . . . .

no problem, they don't check passports at the hospital clinics.

but if something happens at year 6, they'll just review my records....

....and deny coverage because i can't prove i had continued taking my meds
and getting the proper tests!!

 

[Duffey]

no problem, they don't check passports at the hospital clinics.

but if something happens at year 6, they'll just review my records....

....and deny coverage because i can't prove i had continued taking my meds
and getting the proper tests!!

Might as well start searching for another policy.

 

[Lynlw]

I'm also confused on the 2 year 5 year part, does that mean you can't seek treatment or have have symptons of ANYTHING for 2 years.. and anything cancer or heart related for 3 years beyond that?
where did the cancer clause come in?

 

[Star54]

I am in insurance (not medical) but an exclusion is an exclusion. It is what you stated. If they will not cover any treatment for a pre-existing condition, why bother. Find another carrier.

 

[ChouDoufu]

unlike some other insurers that deny coverage outright due to pre-existing conditions,
this one will attach a moratorium period rider. for most conditions, they are excluded
from the coverage for two years, five years for cancer or heart issues. after that, the
policy will revert to normal coverage.

from the quote in the original post, i would think that if the original symptoms (stenosis
and regurgitation) do not reappear i should be okay. but the part about seeking advice
or treatment is the problem. it seems they DON'T want me to get annual echos. NOTE
that echos would be at MY expense, as is all prescribed medications. it's not that
they're trying to cut current costs. it would appear that if i call a doctor to ask if i can
stop cholesterol meds as i've been in range for ten years, then that would in itself
blow the exclusion.

it just seems that if i do anything to ensure that i stay healthy, they will have 'cause'
to deny coverage indefinitely. it's like buying a new car with a 100,000 mile
warranty, but you'll void the warranty if you change the oil or check the air in
the tires. or more appropriately for a health insurance company, it's like offering
coverage for hiv/aids to intravenous drug users, but on the condition that they
NOT use clean needles.

and duffey, i'll be looking, but there just isn't much out there. since my valve is fixed,
i don't anticipate any problems, (there's that new valve in twenty years or so....), at
least nothing in the near future. so i can live with this policy. it's just so damned
stupid.

 

[ChouDoufu]

star, i have no problem with the exclusion. if it's forever, then say that upfront. but
they say i have a 5-year moratorium. if no problems, then they'll cover the
pre-existing condition. that's cool.

but, they are also saying that i must not take any prescribed medication for that
pre-existing condition. and they are also saying i must not get any tests done to
confirm that the condition has changed, either for better or for worse.

what they are saying is they will grant me coverage on the condition that i NOT
try to stay as healthy as possible.

remember, this is just a generic cardiovascular exclusion. the guy with the quadruple
bypass gets the same deal. so if he survives five years he gets coverage, but on the
condition that he never, ever again see a cardiologist. that's insane!

 

[ChouDoufu]

look at it this way. the company says, oh, you had heart surgery, hmm, got one of
them artificial mechanical valves. okay, we'll have to exclude cardio coverage for
five years. at the end of five years, if you've had no recurrence of symptoms, or had
to seek medical advice then we'll remove the exclusion.

oh, yeah, and by the way. that warfarin stuff? you gotta stop taking that.
and no echos, we don't want to know about any leaks.

if you don't bleed out within five years, we'll cover ya. good luck.

oops, almost forgot. here's a welcoming gift for you....it's a month's paid
tuition for knife-juggling school.

 

[Bina]

Same deal with trying to get private life insurance:
It will only pay out if you get hit by a bus, etc.

 

[Star54]

Insurance companies cover their own "a__", and will deny coverage, at the same time try cover yours. I have no idea what an echo costs, but I've had 4 in the past 4 months! I know you do not anticipate problems, but one never knows. While you decide to stay with the policy, still shop around. Wishing you success......
Thank you also, as I am now counting my blessings regarding my insurance through my employer

Linda

 

[Duffey]

Come back to the states, get a job with Anthem BC, they cover everything from the moment of hire.

Now isn't that an attractive scenario?

 

[ChouDoufu]

star...they don't cover echos, whether or not i have a pre-ex condition. this has nothing
to do with their costs. everything outpatient is on me, regardless of the illness.

they are telling me they will cover my pre-ex condition after five years, but ONLY if
i take no preventative measures, that i do nothing to stay healthy.


sorry bina....you signed with us in 2003. that bus that hit you was built in 2001,
and is therefore....pre-existing.

(p.s. echo+ekg $80, treadmill stress test $90)

 

[ChouDoufu]

get a job with Anthem BC

i'm allergic to brimstone....

 

[Jkm7]

I agree it is impossible to meet their terms and still be alive and well in the five years (ie stop taking statin and stop coumadin testing). It seems they want to take your money but do not wish to insure you. Hope you find a company with better terms. Best Wishes.

 

[ChouDoufu]

i'm going to stay with them, at least for now.

the choice is 1) no insurance, or 2) insurance that excludes cardio.

easy choice. my heart has no problems now, so i can do dat. the problem
arises what happens ten years from now? if they're going to set up the
exclusion so that it never expires then i'll be searching for a new carrier.

until then, i don't anticipate any heart problems. regardless, any new
coverage would also have a temporary (i hope) exclusion so i'd be in the
same boat anyway.

i lose nothing by staying with this company in the short term. but i gain
health coverage for everything except the one thing i'm not worried about.

i have several emails in with them now, asking for clarification. "does this
mean you advise me NOT to take prescribed meds?", and "are you advising
me NOT to have annual echocardiograms?" responses pending.

 

[Bina]

I guess they are very paranoid with the possibility of ever having to pay for a valve replacement.
So, all you have to do is hook up with a cute cardio chick and trick her into marrying you at some point in the next 10 years.
Simple...!!

 

[TXWildflower]

That is a real bummer for sure. Something I worry about should I ever lose my insurance. I think it will be difficult to find a carrier that won't exclude anything cardio in some form or if you find it you can't afford it. Insurance companies are out for a profit and they can't profit from paying for all those echos and those meds etc not to mention anything more serious should happen. I hope you can stay healthy, but I think that exclusion is stupid but pretty clear. I work in Life Insurance - not health, but I've seen plenty of exclusion riders. If you were to apply for life insurance you might be excluded for death due to heart valve reasons or else be charged an extra premium for the added risk. That's just the way it is. They have strict underwriting rules to weed out the riff raff.