Archive | Health Insurance Q&A

Here’s a Doosy!

This morning I got to my office to find this gem in my inbox.  I can’t say that she is wrong, and I admire her tenacity.  Look for my comments at the end.

Question: I had health insurance my whole life. I have been a small LLC, member only, business for over 15 years. My health insurance rates began rising 35% annually once I turned 45. On average, in the last 10 years, I paid $5,000/year. I seldom went to the doctors and when I did I have been misdiagnosed. In the last 10 years of having health insurance I paid $50,000 getting reimbursed for less than $500. In 2009, while applying for health insurance I was denied by CareFirst. CareFirst cited high cholesterol (low ratio with 100 HDL that they do not recognized); high eye pressure that I have had for over 20 years and am monitored by an eye doctor (since the early 80s), high BMI (which I am a large boned person) and I was in my late 50s as a woman. While they denied me, they gave me a brochure to Maryland HIP program that is sponsored by CareFirst, so CareFirst takes no risks and gets the overhead/profit. The cost would be around $4000-$5000/annually with a higher deductable a  nd ineligibly for any HSA. I decided not to bite.

I am angry because in my lifetime I have paid over $100,000 and maybe was reimbursed for less that $10,000 if even that. What happened? I was suckered. I was lead to believe that I would have coverage since I was paying into the system my whole life. My advice to all young people and all people is to stay out of the health insurance programs because they take your money for profit and they drop you as you age and become more risky. Health insurance only want to make high bonuses off anyone’s policies. Health insurance companies will cover you only if you are healthy and if you show signs or are statistically a risk, because of getting old, they will drop you.

My great grandparents and grandparents lived into their nineties and never needed much health care, so I will rely on my genes. I mainly wanted insurance for accidents, especially careless people that text and drive.

Another thing I went to my doctor with pains on my left side (stomach). Blood test were taken and the doctor diagnosed me with acid reflux, which I never had or have had. I received insurance statements that my doctor submitted a claim for the blood test, along with LabCorps claims, twice. The doctor and LabCorp tried billing me for the difference. The funny thing is 60% was covered by insurance the 1st time and the other 40% was cover the second submittal by Lab Corp. Then LabCorp had the audacity to try to bill me for the two balances. The total insurance reimbursement was $1000. When I contacted the insurance company to complain, they were nonchalant about it. I asked if they would honor the payee of the insurance and they stated that they only honored the provider. It turned out that I had shingles which no blood test would ever find.

Most individuals have insurance through their companies and never see the insurance statements. I am uncertain if corporations spend time reviewing or even receiving insurance claims about their employees.
The insurance companies have a fraudulent system of over compensation of claims that is one reason why they are insistent people keep getting their insurance through their employers. This over compensation of claims distorts the health care costs.

I don’t feel I need advice from you. I have resolved not to participate in such fraudulent systems as health care insurance. Believe me there are plenty of older women small business owners who have similar stories as mine. My advice to you is to get the word out that the health care and health insurance companies should not be for profit. Once this Country’s health care system is not for profit, then perhaps health care can again be an honorable profession. In the meantime, I will do everything I can to get the word out to the young not to carry health insurance, instead save their money and after 40 years they will have $200K to $300K to cover what ever health issue they have.


Well this isn’t actually a question I don’t think, and I have no idea who this woman is,  much less why she wrote this on my health insurance contact form, or what her goals were in writing it.  I will say it is extremely well written and she is obviously very intelligent and of course, bitter.

Where she is wrong, is her understanding of the word insurance.  Insurance is a transfer of risk.  Similar to auto insurance in fact.  Just because you pay into a policy does not mean it should pay out unless the peril comes to fruition.  I’m sure she has not recovered all of her car insurance premiums back either.

Where is she is 100% correct (and what makes her mistake above almost irrelevant), is that health insurance should be a right not a privilege.  She has been paying into an insurance plan for many years faithfully and now that she can’t find a suitable plan at an affordable price she is right to scream!

Lets draw a parallel to auto insurance, had she wrecked her car several times her auto insurance would be extremely expensive.  But as she said, she has not had health claims to warrant these rate ups.

Thus, she is being rated based on her age which is a factor she cannot change.  Because health insurance is subject to risks you cannot avoid, it should be a government program, much like the fire department.  The fire department used to a private enterprise, until obvious hazards became clear.  Health insurance should be a public utility in the same way.

Sadly, its not and indeed we profit from that fact.  But we are the best of the bunch who will promise to help you even if we make no money on the transaction.

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Benefits Questions on Aetna Group Policy

Question–I’m a female and I am an employee (full-time bank teller) with Bank of America, in Atlanta, Georgia. The health benefits that they provide are through Aetna and they provide me health, dental and vision, and no maternity or OB-GYN coverage, which is okay with me.

However, I’ve NEVER used the coverage, and I became pregnant and stayed away from work on unpaid leave, and my fiancee (now husband) was supporting me paying all my bills.  But then he became ill, and now he himself is in hospice and is sick.  Meanwhile, we did not pay Aetna for two reasons; firstly, the amount owed became outrageous since they were not able to collect anything from my payroll check from the bank, since I was on UNPAID leave, and secondly, Aetna did not want to accept my offer of $100 per month for a $600 bill, which I think is ridiculous.

Aetna said that they could not accept a payment arrangement, but they could arrange for monies to be taken from my check. On another note, today, I opened my check, and for a third time, $300 is missing.  I have some savings and family members are helping me, but these things will soon run out, and that coupled with this situation with Aetna could cost me everything, my apartment and car.  I could lose literally everything….all because of Aetna.

My credit is in the 800s, THANK GOD, which gives me no reason at all to file bankruptcy, which I don’t think would even help a health benefits case anyway. Also, please understand that Bank of America has NOTHING to do with this. They always transfer me to Aetna when I call.  Tomorrow is Monday, and I’m calling first thing in the morning to see if they will cease collecting money from my check. I’m not trying to avoid paying the bill, but I cannot do it on their terms, and what’s more, I did not sign anything.

The benefits package was sent to me after I clicked a “yes” box on my Bank of America employment application, when it asked did I want to enroll in benefits. There was nothing in the benefits packet that said anything relating to what they’re doing to me. I do have an attorney, but since I’m paying them through a payment plan, the work that they do for me is limited until they’re paid in full. So My question is this:  Does Aetna have a legal right to continue to do this, causing me to lose everything? Please advise.

Answer-  I really feel for you and wish I could do something concrete like call or pressure Aetna to make an exception this one time but they simply won’t listen to me, especially as this is group business related not individual.  That being said, the answer to your question is pretty simple.

When you sign up for health benefits, you sign up for a whole year or enrollment period, in most situations, although some employers/insurance companies will let you cancel during the year.  Bank of America sounds like it does not let you cancel.

However, based on what you are saying about your husband getting seriously sick it might be a huge mistake to try to cancel even if you could.

If you have any of the following events occur though you might be able to wiggle out of the plan;

- Divorce or change in the marital status
- death of the dependent
- change in the dependent status
- change in your employment status

I would not recommend divorcing your spouse (or killing him) to get out of your insurance bill.

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West Virginia Maternity?

Today we got this question from Amanda regarding maternity in the state of West Virgina.


Comments: Can you please tell me if BCBS is the ONLY provider who offers maternity coverage in WV.  I am having a terrible time identifying other carriers who provide maternity coverage.  And is WV the only state with this problem?

Thank you kindly,

Amanda W.

Actually Amanda, Coventry also offers maternity in West Virgina, but only on 3 plans including the A13, A14, and the Classic Copay 80.  Luckily for you, we sell both Coventry and Blue Cross, and I recommend you call our sales floor at 888 803 5917 to help you navigate this complex issue.

Additionally Medicaid also provides maternity coverage as evidenced below.

POVERTY-LEVEL PREGNANT WOMEN AND INFANTS UNDER AGE ONE – Pregnant women and children under age one with family income at or below 150% of the current Federal Poverty Level (FPL). No asset test. Children born to Medicaid eligible mothers remain eligible for 1 year after birth without the need for a Medicaid application when the child remains in the home with the mother.

There is also this document from the West Virgina Health and Human Resources Department on maternity including perinatal care and improving pregnancy outcomes.

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Endocarditis & Health Insurance Question

Got a great question today from James in Virginia.

Question: I’m in the process of changing jobs, and I currently have group coverage through United Health Care, as a Walgreen’s employee. I’ve been covered for about three years now. A few months before I became employed there, I became suddenly and dangerously sick, and it turned out I contracted a case of endocarditis. One of the contributing factors was my congenital heart defect, called a Ventricular Septal Defect (VSD). I have since fully recovered and am likely healthier now than I was before I became ill. I have begun the process of looking for a private insurance policy, as the job I’m preparing to take doesn’t offer group coverage. I have already been turned down by Humana, so before I go applying to every Tom, Dick, and Larry in the industry, I wondered if you might have any idea which companies might offer me the best chance of finding coverage. I am a resident of Virginia. THANK YOU for any help you can offer!




Well its a great question James and a year ago I would have been under duress to provide a great answer but now due to PCIP, we should apply with one more carrier so we can show 2 declines.  Once we are declined again we can go to PCIP and get a great plan for way less than an individual plan would cost anyways.

However, what about Endocarditis itself?  Is it insurable?  Endocarditis is considered insurable by some carriers, but only after 3 years of being disease free and at a very substantial premium.  Most carriers like Coventry (check the Coventry Underwriting Guidelines here) call it an immediate decline.  In any case, PCIP will likely be the best place to end up.

What is Endocarditis and Why Is not Insurable?

Endocarditis is an inflammation of your heart’s inner lining. The most common type, bacterial endocarditis, occurs when germs enter your heart.  Endocarditis is uncommon in people with healthy hearts which is why most insurance companies want to avoid the condition. People at greatest risk of endocarditis have a damaged heart valve, an artificial heart valve or other heart defects.

Endocarditis typically occurs when bacteria or other germs from another part of your body, such as your mouth, spread through your bloodstream and attach to damaged areas in your heart. Left untreated, endocarditis can damage or destroy your heart valves and can lead to life-threatening complications. Treatments for endocarditis include antibiotics and, in severe cases, surgery.

Endocarditis has evolved into several variations, keeping it near the top of the list of diseases that must not be misdiagnosed or overlooked. Endocarditis can be broken down into the following categories:

  • Native valve endocarditis (NVE), acute and subacute
  • Prosthetic valve endocarditis (PVE),[8] early and late
  • Intravenous drug abuse (IVDA) endocarditis


 Follow Up from James


Sorry it’s taken me so long to get back to you. Recently I’ve started my new job, and for the time being, I’m working 7 days a week. Are there any evenings which I might be able to call and reach you after 5pm? That’s pretty much the only time I’m free to call, and I want to see if you can help me get the coverage I need. It sounds like you can. I may be willing to fall back on PCIP coverage as a last resort if it’s completely necessary, because in addition to myself, I’ll need coverage for my daughter as well. But for various reasons, I’d much rather avoid relying on a government-sponsored health plan. If I can afford to keep my coverage in the private sector, I’m willing to pay a higher premium, so long as it’s not so high I can’t afford it. Right now, I’m paying Walgreen’s approximately $270 a month for the coverage for myself and my soon-to-be 4 year old daughter.


Also, I’m honored you chose my question for your blog. I’d love to have a link to the blog so I can see it for myself. Thanks! Talk to you soon. Thank you again for making yourself available to help me with my health insurance coverage.

Follow Up Answer to James

Well James, I am glad to hear you are working and getting by in this tough economy.  You can call our office anytime at 888 803 5917, most nights we (including me) are here until 7pm.  Your daughter assuming she is healthy can go on KidCare depending on which state you live in (Virginia does have a KidCare program) and generally costs $100 or so per month.  I do realize that is also a government plan, but it is more of a state thing than a federal government thing.  Though to be precise the program is probably funded by the federal government.

In any case, we can help you though we might need to get creative for the 6 months before you can get PCIP.

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Hemochromatosis…a great reason to have a good health insurance policy.

Hemochromatosis is a disease where too much iron accumulates in your body, often described as iron overload. Iron is a mineral, and too much of it becomes toxic to your organs, including the pancreas, liver and heart, leading to diseases including diabetes, heart disease, and cirrhosis or cancer of the liver.

In some people the iron accumulates in the part of the brain that produces chemicals, and causes depression. The main type of hemochromatosis is caused by a genetic defect, passed on by both parents. It is often not diagnosed until significant damage has been done to the organs, and can eventually result in death when the organs shut down or become so severely damaged by the iron that they cease to perform their normal functions.

Diagnosis can be easily done through blood testing, and once diagnosed, regular treatments can lead a person to live a normal life, providing the organs have not yet suffered serious damage. If you are diagnosed as having hemochromatosis, you will requires lifelong blood testing and treatments to remove the excess iron from your body.

You may not realize that you are at risk for this genetic disease because your parents might be carriers and not express the symptoms of the disease themselves, or one or both of your parents may have suffered from various diseases, and perhaps died from them, not realizing that their diseases were secondary diseases resulting from untreated iron overload. A good health insurance policy will protect you from financial complications if you end up with a diagnosis for hemochromatosis and require lifelong testing and treatments. Ask your doctor to test you for this disease, which can be ruled out with a blood test.

HHC is not an automatic decline condition by every health insurance company nor is it automatically a condition for acceptance through PCIP.  Insurance companies will make case by case decisions regarding the insurability of each person.

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Premium Increases

Here is a Question from Anonymous in Florida:

What Determines the Premium Increases for Individual Health Insurance and How High Can They Go?


Answer:  Well Anonymous this is actually a great question that we get asked time and again.  The first part of your question is about Premium Increases.  On individual health insurance, premiums can only be increased for an entire demographic.  So for instance, they can’t target John Doe aged 40 in Miami for his own 30% increase.  Either everyone gets it or nobody gets it.  But, there can be multiple increases for the same region but in the different age bands.   So all the 40-45 year old males might get a 15% rate increase and all 18-24 males might only get a 4% increase.   Additionally, when it comes to domiciled health insurance companies (which is all of the health insurance companies that East Coast Health Insurance represents, except United Health Care) their rate increases must be approved by the state.  Oftentimes this means absolutely nothing as we have seen 20% increases year over year.

Health Insurance margins are pretty much constant at the industry average of 4% so that is why you might see uneven premium increases across various demographics.  This would occur because lets say Cigna had an exceptionally bad loss on 40 – 45 year old males, so they have to hit this demographic harder than others.  And, this might only occur in a particular city or county so the difficulties in guessing rate increases becomes even more difficult unless you are able to look at detailed Actuary Tables for the results in a certain demographic.

But to answer the last part of your question individual health insurance premiums can go up as high 30% if they are approved by the State.  In practice, however the average annual increase for domiciled health insurance companies is 12%.   Many companies like Humana and United Health One raise their premiums 3% every quarter for new enrollments.  These increases are passed on to the older members on their policy anniversary date in order to have homogeneous premiums for various demographics.

What makes up premium increases besides claims experience?  Inflation (this is the most scary one), rising health care costs (this is the 2nd most scary one), and of course the fact that you are a year older unless you figured out a way to age backwards like Benjamin Button.  The scariest thing is that in the next few years health care and health care costs will make up nearly 25% of our GDP unless someone fixes our health care system and the current bill that is headed for the Senate does not even address rising health care costs.


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