Should Someone With a Pre-Existing Condition Be Denied Health Insurance Research Paper

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Pre-Existing Condition and Denial of Health Insurance

The focus of this work in writing is to examine whether the individual with a pre-existing health condition should be denied health insurance coverage. Toward this end, this work will examine the literature in this area of study. A pre-existing condition is "a medical condition that existed before someone applies for or enrolls in a new health insurance policy. It can be something as prevalent as heart disease which affects one in three adults -- or something as life-changing as cancer, which affects 11 million Americans.' (HealthReform.gov, 2011) A large number of the American population has health conditions that can be qualified as pre-existing conditions by insurance companies. It is reported that insurance discrimination

"...based on pre-existing conditions makes adequate health insurance unavailable to millions of Americans. In 45 states across the country, insurance companies can discriminate against people based on their pre-existing conditions when they try to purchase health insurance directly from insurance companies in the individual insurance market. Insurers can deny them coverage, charge higher premiums, and/or refuse to cover that particular medical condition." (HealthReform.gov, 2011)

Reported as well in a national survey conducted recently are estimations stating that approximately 12.6 million "non-elderly adults -- 36% of those who tried to purchase health insurance directly from an insurance company in the individual insurance market -- were in fact discriminated against because of a pre-existing condition in the previous three years. In another survey, one in 10 people with cancer said they could not obtain health coverage, and six percent said they lost their coverage, because of being diagnosed with the disease." (HealthReform.gov, 2011)

It is reported as legal in nine U.S. states for insurers to reject individuals applying who are "survivors of domestic violence, citing the history of domestic violence as a pre-existing condition. Even when offering coverage, insurers can exclude whole categories of illnesses related to a pre-existing condition. For example, someone with a pre-existing condition of hay fever could have any respiratory system disease -- such as bronchitis or pneumonia -- excluded from coverage." (HealthReform.gov, 2011)

It is reported that thousands of individuals lose insurance every year through a practice called rescission. Rescission means

"When a person is diagnosed with an expensive condition such as cancer, some insurance companies review his/her initial health status questionnaire. In most states' individual insurance market, insurance companies can retroactively cancel the entire policy if any condition was missed -- even if the medical condition is unrelated, and even if the person was not aware of the condition at the time. Coverage can also be revoked for all members of a family, even if only one family member failed to disclose a medical condition." (HealthReform.gov, 2011)

In fact, a recent investigation by Congress into the practice of rescission states findings that almost "20,000 rescissions from three large insurers over five years, saving them $300 million in medical claims11 -- $300 million that instead had to come out of the pockets of people who thought they were insured, or became bad debt for health care providers. At least one insurance company has been found to evaluate employee performance based in part on the amount of money an employee saved the company through rescissions. Simply put, these insurance company employees are encouraged to revoke sick people's health coverage." (HealthReform.gov, 2011)

II. Scope of the Problem

Case Study 1

In 2010 a newborn as denied medical insurance coverage because it was born with a heart defect. Surgery would have corrected the baby's condition but within days of the child's birth the parents of the child learned that the application of health insurance to cover their child had been denied due to a pre-existing condition. The couple was required to pay out of pocket for the child's life saving surgery.

Case Study 2

In another case a 2010 report states that a 45-year-old mother and divorcee was denied health insurance coverage due to a pre-existing condition in the form of a rare genetic disease called C4 Complement Deficiency involving the immune system having 'inadequate levels of complement proteins' leaving the body prone to infections. Carlson states that it makes her body "unable to process bacteria and viruses efficiently" resulting in her body attacking itself. It is a condition similar to lupus.

Case Study 3

In yet another reported instance a six-year-old girl may never hear again due to being denied health insurance coverage based on a pre-existing condition.

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The report states that it is

"One of the worst abuses of the private health insurance industry s its practice of denying claims to pay for necessary care for patients. This practice has become so rampant in the industry that a recent study by the California Nurses Association found that a whopping 21% of all insurance claims filed in the first half of 2009 in the state of California were denied by insurers." (TP News, 2010)

Madison Leuchtmann of Franklin County, Montana was born with "bilateral atresia, which means she lacks ear canals in both ears. In order to hear, she wears a special device on a headband that allows her to make out sounds. Despite her disability, Madison is at the top of her kindergarten class and is slowly learning to read. Yet Madison, due to her growth, will soon require a new hearing implant to be able to recognize sounds. Her hearing and speech therapist warns, "If she doesn't get her implants by age seven, she's not going to be able to blend her words. … She won't be able to hear herself [talk]." Madison's pediatrician, Dr. Randall Clary, also insists that without the implant, the girl may never be able to hear again. (TP News, 2009)

Cigna, the insurance company is reported as having issued "one denial after another, flatly refusing to cover the $20,000 bill for the implant. In a written statement to the local news station Fox 2, Cigna explained, "It is not unusual for commercial benefit plans to exclude hearing assisted devices…" (TP News, 2009) The Dr. For the child states, "This is obviously medically necessary. You have a child that has no ear canals!" (TP News, 2009) The Dr. reports that he sees "these sorts of denials on a weekly basis." (TP News, 2009) According to one report, "A large proportion of Americans have health conditions that insurance companies can qualify as 'pre-existing conditions'. (Healthreform.gov, 2011)

III. U.S. Department of Health and Human Services Report- May 2011

The U.S. Department of Health and Human Services (HHS) announced on May 31, 2011 that new steps were being taken to reduce premiums and to make it much easier for individuals to enroll in the Pre-existing Condition Insurance Plan. The report states that premiums for the Federally-Administered Pre-Existing Condition Insurance Plan "will drop as much as 40% in 18 states and eligibility standards will be eased in 23 states and the District of Columbia to ensure more Americans with pre-existing conditions have access to affordable health insurance. The Pre-Existing Condition Insurance Plan was created under the Affordable Care Act and serves as a bridge to 2014 when insurers will no longer be allowed to deny coverage to people with any pre-existing condition, like cancer, diabetes, and asthma." (U.S. Department of Health and Human Services, 2011, p.1)

According to HHS Secretary Kathleen Sebelius "The Pre-Existing Condition Insurance Plan changes lives, and in many cases, literally saves lives. These changes will decrease costs and help insure more Americans." (U.S. Department of Health and Human Services, 2011, p.1) The temporary PCIP program was created by Congress

"…as part of the Affordable Care Act to help uninsured Americans with a variety of medical conditions get affordable coverage rather than be locked out of the system by insurance companies. In 2014 and beyond, insurers will be prohibited from denying coverage to anyone with a pre-existing condition and new competitive marketplaces called Health Insurance Exchanges will give people the opportunity to shop for the policy that best suits their needs. Millions of Americans also will receive tax credits to help make coverage affordable." (U.S. Department of Health and Human Services, 2011, p.1)

It is reported that PCIP provides "…comprehensive health coverage, including primary and specialty care, hospital care, prescription drugs, home health and hospice care, skilled nursing care and preventive health and maternity care. It limits annual out-of-pocket spending and does not carve out benefits the people need. Eligibility is not based on income and people who enroll are not charged a higher premium because of their medical condition." (U.S. Department of Health and Human Services, 2011, p.1)

IV. The Debate

The New York Times reported on March 28, 2010 that only days following President Obama's signing of the new health care law " insurance companies are already arguing that, at least for now, they do not have to provide one of the benefits that the president.....

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