Consumer Question - Post Claim Underwriting?

[Guest]

I have a question as a consumer (I apologize for the length). We have an individual health insurance policy with a well-known, large carrier. We went through all the pre-application questions, both with an agent for the paper application, and on the phone with a company rep. We disclosed everything, including surgery I had to put a fractured foot back together. My foot has a few pins it but I haven't seen a doctor for it in over a year and don't plan to. We were approved quickly with no riders.

A month and a half after we get the policy, I go the my internist for a routine physical. I tell her I've been tired, my periods have been a lot more irregular lately, blah, blah, but nothing major. She does a CBC, discovers I'm pretty anemic and refers me to a new GYN. The GYN sees me the following month, does an ultrasound to find out why I'm so out of whack and discovers a nice big (benign) fibroid. This is a total surprise to me. Then, as soon as our insurance provider gets this claim, they pend it and ask for records from the GYN. After my subsequent follow-up with her, they then ask for records from my internist. A few weeks after that, I get a letter with a bunch of forms, asking for a list of all the doctors I've seen in the past 5 yrs. and a consent form they want me to sign to get info from my doctors. The insurance company ends up denying both GYN claims, saying they're waiting on information from me and the providers.

Well, the providers sent in their records; I haven't sent in anything yet. Here's why - I went back and got the records from the previous GYN I'd seen a little over a year ago for my annual. I'd made some vague complaints about irregular periods then, but she passed it off as just getting older, it happens,etc. Turns out, however, in the records, she put down "menorrahagia" as a "diagnosis" for this (was not ever told to me) and also that I was "anemic" (again, not told to me; after reading this, I had a faint memory of her nurse telling me I was "low" on iron but that's it). So, the way I see it, I'm basically screwed if I consent to my older records being obtained because we didn't list these two things as "pre-existing" and they're on the application, plain as day. And, as it turns out, I will need some procedures to address this issue with the fibroid.

Obviously, had I known what was actually in those records, I would have disclosed it. I'm smart enough to know that it wouldn't benefit me not to do so. I'm afraid they'll rescind the policy because of this. Any thoughts? BTW, this is a company that supposedly doesn't do post-claim underwriting, based on an older post I'd read in this forum. Well, from here it sure seems like they do.

 

[Crabcake Johnny]

First of all I feel for you - this is the stuff that happens to good honest people who feel they are disclosing everything on the application.

Based on what you posted you unfortunately have a very high chance of having your policy rescinded - which I'm sure is not the response you're looking for.

I also wish I could give you some recourse if the carrier rescinds. Actually, just based on what you posted the fault seems to lie with your doctor if he/she did not disclose those conditions.

 

[Guest]

That's exactly what I was afraid of and precisely why I didn't provide the info the insurance company is requesting.

As far as the doctor goes, I'm guessing I'm out of luck there, as well. If it's in the records, then it's basically her word against mine, right?

 

[Crabcake Johnny]

Indeed. The reality is you need to prepare for the worst - which is having your policy rescinded. You cannot fault the carrier and it's "he said she said" with your doctor's office.

 

[somarco]

Post claim underwriting is prohibited in most states. Can't say about Alabama.

My guess is you are talking about Blue.

The good news is, Blue has been slammed in other states, most notably CA, for arbitrarily denying claims and rescinding policies under the pretense of filing a fraudulent app.

The bad news is, Blue practically owns AL when it comes to health insurance.

My suggestion is to fight it with everything you have. New apps approved in GA last summer give Blue broad powers to review applications for almost anything. I have never seen a carrier say on an application they can rescind a policy based on information they could have reviewed at time of application, but chose not to.

A carrier can review apps up to 2 yrs after the fact based on new medical data, but not based on claims filed. It seems like semantics, but it is really wiggle room giving them broad discretion.

You have a Catch 22 situation. If you don't consent to release records, they can deny this and any future claims. If you do consent, it can work to your advantage. The carrier will have to prove you knew of the "condition" and willfully failed to disclose in an attempt to file a fraudulent application.

You have no choice but to fight any adverse action by the carrier. One thing that seems to work in favor of consumers is the 6 o'clock news. The media is sympathetic to a good story about the big, bad carrier denying claims and carriers, even those that are 800# gorilla's, know it is better to cave than to play the bully card.

 

[Guest]

No, it's H*****, not Blue.

And we're in SC. So they are within their legal rights to do what they're doing.

I really don't know what to do. We got this insurance through an agent here, who advised me to send in the papers. He said, (and I quote) "The worst case scenario is they can rescind your policy." I haven't told him the whole story of the older medical records; I guess I'm afraid of divulging to much info. Is it worth my while to explain this to him? Is he obligated to tell the ins.company?

Best case, I suppose, would be that they rider this (most likely indefinitely) and rate us up as well. Neither scenario is a good one, although recension would leave us all uninsurable. A rider would leave me with all the expenses out of pocket, anyway (and they would be substantial). I really feel that they would just drop us, though. Either way, I would be out lots of money. They have, however, paid my other claims from my internist. It's just the GYN claims they're looking at.

 

[HealthGuy]

I too have had Humana recind policies...I think they are good at trying to do this.

 

[Crabcake Johnny]

Although in this case you didn't know about the conditions we also have to be careful here. The carriers also need to protect themselves from people who set out to lie.

If someone's diagnosed as diabetic, set out to lie on the app then get caught is it as easy as saying "I had no idea they diagnosed me as diabetic. All the doctor's office said was something about my sugar and just to watch my diet."

Post claims UW gets a bad wrap - but get car insurance using your aunt's zip code in her nice area when you live in the city, put 80,000 miles on it when you said you drive 20,000 - cause a major accident and see if that claims is paid.

 

[moonlightandmargaritas]

I too have had Humana recind policies...I think they are good at trying to do this.

I have about 120 cases on the books with H1, and have never had a problem.

 

[somarco]

Paul, you & I are in the same situation.

Got a case now, guy got sick, ran up over $100k in claims over 3 weeks. H1 is investigating.

I got my client to sign a HIPAA release so I am now involved in the review process. Based on conversations, I don't expect any problems.

Been down this road before with other carriers. Have only had one rescission and that one was spot on.

If you are having problems with rescissions then you are doing something wrong.

Sam5, I thought you were from AL because of your "flag". If your agent is worth his salt he will get involved and go to your defense.

Based on what you have posted so far, and what I know about Humana, I believe it will work out.

BTW, the underwriting review is based on diagnosis, not claim size. They are looking for symptoms that manifested before the date of the application that were discussed and a treatment plan prescribed. Doesn't sound like that happened here.

I don't want to minimize the situation. What they are really concerned with is fraud and misrepresentation. It does not sound like that happened here.