Tue
Sep 22 2009
10:59 am

California-based Consumer Watchdog has obtained internal underwriting policy documents for several California insurers that detail exclusions for pre-existing conditions:

In the wake of news reports that a history of domestic violence is considered a "pre-existing condition" by many health insurers, today Consumer Watchdog released internal insurance company documents showing that firefighters, police officers, war correspondents, expectant fathers, pregnant women and patients with asthma, acne, allergies, and toenail fungus will often be denied health insurance policies.

The list of pre-existing conditions is long, and includes just about every illness. Rescission provides for denial of claims or detailed investigation of claims related to any of these conditions.

So exactly what is it they cover? Not much apparently. Maybe it should be called "accident insurance" (unless you're a dockworker or flight instructor).

Underwriting policy documents:

PacifiCare (subsidiary of United Health Group)
Blue Cross of California (subsidiary of WellPoint Inc.)
Blue Shield of California
Health Net
Consumer Watchdog press release

UPDATE: An example list of declinable pre-existing conditions from the Blue Shield policy...

continued...

DECLINABLE CONDITIONS
Acromegaly
Adoption In Progress
AIDS
AIDS-related complex (ARC)
Alzheimer’s
ALS, Lou Gehrig’s
Amputation, Single or
Bilateral Foot or Leg
Anaplastic Carcinoma
Anemia, Aplastic
Anemia, Cooley’s/
Mediterranean/Major
Thalessemia
Anemia, Cooley’s/
Mediterranean/Minor
Thalessemia with symptoms
Anemia, Hemolytic,
Auto-Immune
Aneurysm – Aortic,
Abdominal, Thoracic
Aneurysm, Cerebral Artery
(Brain) with Stint/Shunt
Angina
Angioplasty
Aortic Obstruction
Aortic Valve Stenosis
Apnea (see Sleep Apnea)
Arnold-Chiari Syndrome
Arteriosclerosis
Arteriovenous
Malformation, unoperated
Arteriovenous
Malformation, operated
but shunt in place or
with residuals
Arteritis, Necrotizing
Arthritis,
Osteoarthritis severe
Arthritis, Psoriatic
Arthritis, Rheumatoid:
chronic, severe or
under treatment
Atrial Fibrillation on
blood thinners
Atrial Tachycardia
Asbestosis
Back sprain/strain, chronic
Banti’s Disease
Barrett’s Esophageal
Ulceration
Basal Cell Skin Cancer,
multiple removals in one site
Behcet’s Syndrome
Bicuspid Aortic Valve
Bipolar Disease
Bladder Stones, present
Bradycardia with pacemaker
Breast Implants, silicone
Breast Microcalcifications
– severe after biopsy or
present without biopsy
Bypass Surgery – all cases
Cancer, all non-localized
Cancer, Liver
Cancer, Ovarian
Cancer, Pancreas
Cardiomyopathy
Carotid Artery Disease
Carotid Endarterectomy
Carotid Bruit
Cellulitis, Chronic
Cerebral Palsy: under age
five or moderate to severe
Chorea, Huntington’s
Chronic Obstructive
Pulmonary Disease
(COPD): moderate to
severe or smoking
Christmas Disease
Cirrhosis
Cleft Lip/Palate:
unoperated under age 19
Coagulation Defects
Colitis, Ulcerative:
unoperated or with
partial colectomy
Colitis, Ulcerative with or
ileostomy or colostomy
Congestive Heart Failure
Connective Tissue Disease
Cor Pulmonale
Corneal Degeneration
Corneal Ulcer: chronic
and unoperated
Coronary Artery/Heart
Disease
Cretinism
Cystic Fibrosis
Cytomegalovirus
Dandy Walker Syndrome
(see Hydrocephalus)
Delirium Tremens
Demyelinating Disease
Dermatomyositis
Diabetes with Hypertension
or over weight guidelines
or on insulin pump
Diabetic Neuropathy
Diabetic Retinopathy
Dialysis
Dysplastic Nevus Syndrome
Endometriosis: symptomatic
before or after surgical or
natural menopause
Esophageal Ulcerations
or Varicosities
Factor VIII, IX or XI
Disorders/Deficiencies
Fallot’s Tetrology
Fanconi’s Syndrome
Fasciitis: chronic
or recurrent
Fatty Liver
Fibromyalgia
Flexion Contracture
Friedrich’s Ataxia
Gallstones, unoperated
Gangrene, Diabetic/
Arteriosclerotic
Glomerulonephritis:
Nephritis, chronic
Glomerulosclerosis
Goodpasture’s Syndrome
Gout: Tophaceous or with
renal involvement
Guillain-Barre Syndrome:
present or with residuals
Hamman-Rich Disease
Hansen’s Disease (Leprosy)
Heart Attack, Myocardial
Infarction within 10 years
Heart Enlargement
Heart Pacemaker
Heart Valve Replacement
Heart Valve Stenosis
Hemangioendothelioma
Hemochromatosis
Hemoglobinuria
Hemophilia
Hepatitis: all those other
than A, B or E
Hepatitis: any type – present,
chronic or persistent
Herpes Zoster: eye or ear
involvement
Hirschsprung’s, unoperated
Hodgkin’s Lymphoma
Huntington’s Chorea
Hyaline Membrane Disease
within 2 years
Hydrocephalus
Hyperprolactinemia
with tumor
Hypertension with Diabetes
or Renal Disease or
History of Stroke
Hypertension over weight
guidelines or uncontrolled
or hospitalized within
1 year
Hypogammaglobulinemia
Immunodeficiency Disorder,
except HIV infection
Infertility treatment within
past 2 years
Interstitial Cystitis
Ischemic Attack, transient
Ischemic Heart Disease
Joint Replacements: both
knees or hips
Joint Replacements:
multiple surgeries or shoulder,
elbow, wrist, ankle
Kaposi’s Sarcoma
Kidney Dialysis
Kidney Stones, present
Kimmelstiel-Wilson
Syndrome
Kleinfelter’s Syndrome
Leprosy (Hansen’s Disease)
Leriche Syndrome
Leukemia
Lou Gehrig’s Disease
Lupus Erythematous:
discoid – chronic
Lupus Erythematous:
systemic
Lyme’s Disease: chronic
or symptomatic
Lymphedema
Macular Degeneration:
exudative
Major Depression
Manic Depression
Marfan’s Syndrome
Mitral Valve Prolapse:
more than trace regurgitation
or not on prophylactic
antibiotics
Mitral Valve Stenosis
Multiple Myeloma
Multiple Sclerosis
Muscular Dystrophy
Myasthenia Gravis
Myocardial Infarction
within 10 years
Nephrectomy: persistent
renal or cardiovascular
abnormalities
Neuroblastoma
Neurofibromatosis
Nevus: Dysplastic Syndrome
or Giant Melanocytic
Non-Hodgkin’s Lymphoma
Obesity with Prior Surgery
Osler-Weber-Rendu Disease
Otosclerosis, unoperated
Pacemaker
Pancreatitis: recurrent
or chronic or secondary
to alcoholism
Paralysis: Quadraplegia,
Paraplegia
Parkinson’s Disease
Pelvic Inflammatory Disease
(PID): present
Pemphigus
Pericarditis: constrictive
Peripheral Vascular Disease
Phlebitis, Deep Vein: present
or on anti-coagulants
Pleurisy, unresolved
Pneumocystis Carinii
Polio with bladder or bowel
residuals
Polycystic Kidney
Polycystic Ovaries (Stein
Levinthal Syndrome) without
removal of ovaries
Polycythemia Vera
Polyp, anal or rectal: more
than 4 and/or unoperated
Polyp, bladder: present or
recurrent
Polyp, gastrointestinal:
unoperated
Pott’s Disease
Pregnancy of self, spouse
or significant other
Progeria
Prostate Stones
with Prostatitis
Psoriasis, Severe
Psoriatic Arthritis
Psychopathic Personalities
Psychotic Disorders
Pulmonary Embolism:
present
Pulmonary Fibrosis
Pulmonary Hypertension
Pulmonary
Osteoarthropathy
Pulmonic Stenosis
Quadriplegic Paralysis
Reiter’s Syndrome: within
6 months of diagnosis
Renal Failure: chronic
or end stage
Retinoblastoma
Rett’s Syndrome
Rheumatic Heart Disease
Rotator Cuff: unoperated,
symptomatic
Sarcoidosis
Schizophrenia
Scleroderma: recurrent,
extensive or diagnosed
within 1 year
Sezary’s Syndrome
Shingles: eye or ear
involvement
Shunts or Stints
Sick Sinus Syndrome
Sickle Cell Anemia
Sjogrens Syndrome
Sleep Apnea: obstructive
or poorly controlled or
requiring CPAP (continuous
positive airway pressure)
Spina Bifida, Cystica:
unoperated or operated
with residuals
Spina Bifida, Occulta:
unoperated under age 20
Spinal Curvature: Kyphosis,
Scoliosis or Kyphoscoliosis,
unoperated
Stein-Leventhal Syndrome
(polycystic ovaries)
Stroke within 10 years
Subdural Hematoma:
unoperated
Superior Vena Cava
Syndrome
Surrogacy Planned within
2 years with surrogate
mother or applicant
as surrogate
Syphilis: tertiary
Syringomyelia
Systemic Lupus
Erythematous
Tabes Dorsalis
Tay-Sachs Disease
Temporal Arteritis
Temporomandibular Joint
Syndrome (TMJ): operated
with residuals
Tetrology of Fallot
Thalessemia Major
Thrombocytosis
Tonsillitis: chronic, recurrent
(3 or more attacks per year)
Toxoplasmosis
Tracheotomy present
Transient Ischemic
Attack (TIA)
Transplants:
all except corneal
Transposition of the great
vessels: unoperated
Treatment with AZT, HIVID
or Pentamidine
Trigeminal Pulse
Tuberculosis, Epididymus
Turner’s Syndrome
Ulcer, Peptic: active within
2 years or H. Pylori Positive
Upper Airway Resistance
Syndrome
Urethral Stricture:
chronic, recurrent
Uterine Fibroid Tumor:
unoperated, moderate-tolarge
size
Valve Disease, Valve
Replacement
Varicose Veins: moderate
to severe
Ventricular Fibrillation
Ventricular Tachycardia
Von Recklinghausen’s
Disease
Von Willebrand’s Disease
Wegener’s Granulomatosis
Wolff-Parkinson-White
Syndrome: without
cardiac ablation
200
like
metulj's picture

This is the system that

This is the system that people like Baucus are out to protect. It's really no different than being a bookmaker who has organized crime muscle to back up the ledger. You make money on both sides and just abuse and threaten the folks who don't pay up or complain about the vigorish.

On the other hand, at least California has a rather large number of plans to choose from, unlike say Arkansas.

True happiness is knowing you are a hypocrite. -- Ivor Cutler

Stimulating the economy as best we can!

Further stimulation with Yoga Wear!

bizgrrl's picture

This is outrageous! The only

This is outrageous! The only solution is single-payer.

Sleep apnea requiring CPAP - auto decline?

I've known several people who have used the CPAP, one who lived into their 80s. I suppose doctors need to be careful on the conditions they find and the treatment or they will have no patients that can afford their services or treatments.

bobbylife's picture

How come?

This is outrageous! The only solution is single-payer.

Seriously. Why? Aren't there other potential solutions that have yet to be tried?

For instance, why not bust the trusts and allow some actual competition into the "free" market? Isn't there at least the possibility that treating the insurance industry like others that are actually subject to antitrust laws would induce some beneficial declines in prices for the former's products?

Why not make recission illegal? It's an abhorrent practice. Why should it not be against the law?

Why not get rid of exclusions for preexisting conditions like the ones listed above? If people pay into the insurance system over the course of time, which they damn well should if they want to receive benefits from it, can insurors not figure out a way to be profitable? I bet they could.

Not everyone pays into the system, so why not offer gentle incentives to people who are healthy and who could afford insurance but simply choose not to, to purchase insurance by making them pay out of pocket for care they receive on the public dime?

metulj's picture

While I like the "bust the

While I like the "bust the trusts" idea, it is important to remember that there would be consolidation after that and you would have a national regime of few options many of which may forgo "unhealthy" regions like the South altogether.

Imagine a MaBell of health care. It's actually more frightening than expanding Medicare by a long shot. Do you remember being able to buy the one (1) phone style available to you? Those were the days, right?

True happiness is knowing you are a hypocrite. -- Ivor Cutler

Stimulating the economy as best we can!

Further stimulation with Yoga Wear!

Andy Axel's picture

Imagine a MaBell of health

Imagine a MaBell of health care.

Or, alternatively, don't. Some things are too horrid to countenance.

____________________________

Dirty deeds done dirt cheap! Special holidays, Sundays and rates!

bobbylife's picture

I dunno.

I was really, really young back in the Ma Bell days. I just remember that the phones were extremely hard to break.

I think a more accessible analogy might be something like Microsoft. I use the wares of Gates, usually, even though I bitch about it all the time. I could use a Mac if I wanted to, and I've played around with open source stuff enough to think, "I could probably make this work."

There's no absolutely perfect solution, but the ones that are out there offer enough flex that anyone can compute. Access to healthcare could be much improved by some judicious regulation that favors consumers, which my probably-too-simple suggestions attempt.

But back to Ma Bell. When I think of Medicare scaled to single payer, that's exactly the kind of monolithic (potential) goatf*ck that comes to mind; part of the reason Medicare works is that it is a piece of a puzzle instead of being the whole thing. What is it about the fact that the government would be running it that makes it seem so much more attractive/effective than if it were being operated by private parties?

talidapali's picture

The problem with the suggestions you are making...

while they are common-sensical is that you and all the other opponents of a public option are relying on the good-heartedness of the insurance industry to do right by their customers. Even though those companies have PROVEN over and over that when it comes down to brass tacks...they will choose profit and make it a priority over the health and well-being of ANY of their customers, from the poorest of the poor to the wealthiest they can attract. The TRULY wealthy don't seem to bother with insurance at all, they just pay out of pocket because they can. Anyone who is not in that upper echelon of income earners is SOL when the insurance company begins weighing the value of your life versus the pay-out they would have to make to help you keep it in the face of a catastrophic disease.

Corporations have been given all the rights and privileges of individual human beings in this capitalistic society of ours, but politicians have not yet managed to legislate a soul or conscience or morality for them yet. So go ahead and trust health insurance CEO's to care about you and your loved ones if you like, I don't...and unlike government, we cannot vote the bastards out of office if we don't like how they do their jobs, ESPECIALLY if they're the only game in town. With government offering a low-cost alternative, big corporations will have to at least make a token show of being responsive to the needs of their clients.

_________________________________________________
"You can't fix stupid..." ~ Ron White"
"I never said I wasn't a brat..." ~ Talidapali

bobbylife's picture

Did you even bother to read what I said?

Legislation NEVER gives anyone or anything a soul or a heart. It just, hopefully, prevents them from behaving badly and/or punishes them when they do.

...you and all the other opponents of a public option are relying on the good-heartedness of the insurance industry to do right by their customers.

Trust health insurance CEOs? Hardly. I'm saying remove some of their more abhorrent options.

Regulation right now favors the interests of the insurance industry. I identify that as very problematic and suggest changing the regulatory environment to as to favor people who need access to healthcare.

You seem to believe that government somehow has more of a soul than do private corporations, and you might believe that a single payer system run by the government will be a real evolution in healthcare access. You're entitled to believe such things, but I don't see any evidence to suggest that you're right. I still remain to be convinced that single payer won't be a step towards a more uniform level of mediocrity at best.

KC's picture

You seem to believe that

You seem to believe that government somehow has more of a soul than do private corporations,

Yeah. An 8 hour work day and child labor laws are really cruel and heartless.

Here's an idea: learn a little American history before you comment again.

The dogmas of the quiet past, are inadequate to the stormy present.
President Abraham Lincoln 1862

bobbylife's picture

Sanctimony is the new cleverness, evidently.

And your point is well-taken. I've studied it, and I now fully comprehend that you're an illogical and uncomprehending dolt of American historic proportions, Gary. The 8-hour workweek and child labor laws are analagous to exactly the kind of regulation I'm advocating with regard to insurors.

But that kind of regulation is an appropriate role for government. Being in the insurance monopoly business is not. So back to the actual issue, which relates to improving access to healthcare. I still remain to be convinced that single payer won't be a step towards a more uniform level of mediocrity at best.

KC's picture

"you might believe that a

"you might believe that a single payer system run by the government will be a real evolution in healthcare access. You're entitled to believe such things, but I don't see any evidence to suggest that you're right."

Medicare hasn't given people access to healthcare? That's why it covers over 40 million people and almost everyone over 65 years of age applies for it, because it's such a lousy system?

Like I said, learn a little history.

The name calling may get you places on other blogs, but on this one I don't think most people are impressed with it.

But then again, if it's all you've got....

The dogmas of the quiet past, are inadequate to the stormy present.
President Abraham Lincoln 1862

bobbylife's picture

In your case, Gary, the name is just an objective descriptor.

No offense intended.

What is your point about Medicare? That it's a monopoly?

My question is, is it better for Medicare to scale to a national single payer system than it is to regulate private insurors differently? If so, why?

Which aspect of history do you suggest I study to find the answer? Labor laws or Medicare? The Korean War? TVA?

metulj's picture

"My question is, is it

"My question is, is it better for Medicare to scale to a national single payer system than it is to regulate private insurors differently? If so, why?"

3% overhead. Game. Set. Match.

True happiness is knowing you are a hypocrite. -- Ivor Cutler

Stimulating the economy as best we can!

Further stimulation with Yoga Wear!

bobbylife's picture

Yeah.

I get that. Does it scale at 3%, though? And does the delivery system function as well or better in all respects at Medicare payment levels?

If the answers to those questions are unequivocally "yes," then I honestly think I'd have to concede the match.

metulj's picture

The overhead at private

The overhead at private coverage plans is 30%. That's an order of magnitude. If single-payer based on Medicare went to 5% overhead, it would be a marginal difference in relation to what goes on at private administrations.

True happiness is knowing you are a hypocrite. -- Ivor Cutler

Stimulating the economy as best we can!

Further stimulation with Yoga Wear!

R. Neal's picture

Medicare has more than 44

Medicare has more than 44 million enrollees and represents 22% of health care spending in the U.S. My guess is that it's the largest insurance program in the world. So yes, it scales.

One problem with Medicare is that the costs are higher per capita than the general population. This is due to the fact that Medicare enrollees are seniors and people with disabilities, who typically have more health problems. If it were spread out to cover everyone it would be more efficient.

My personal experience of observing the care received by Medicare patients is that it is as good or better than private insurance.

bobbylife's picture

Thank you both.

I'm all out of questions for now.

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