Wednesday, March 31, 2010
Three faces wears the doctor: when first sought
An angel’s; and a god’s the cure half-wrought;
But when, the cure complete, he seeks his fee,
The devil looks less terrible than he.
Any analysis of a problem, whether extant or solved, requires an understanding of the terms employed. Thus, it is helpful in the very week in which health care reform became the law of the land that we were offered two examples of the impact the law will have on certain conditions. They are “pre-existing conditions” (PE) and “chronic conditions (CC). PE is specifically addressed and the consequences of CC are addressed. The definition of “pre-existing condition” was brought to us courtesy of Houston Tracy.
Houston was born on March 15 and at the time of this writing is only two weeks old. Too young to be instructing anyone in much of anything, he has in fact served as a tutor for his parents in diseases of the heart and etymology.
Houston was born with a congenital heart defect that was “a transposition of the great arteries.” Houston was taken to Cook Children’s Medical Center in Forth Worth and underwent surgery to correct the defect. If Houston’s parents are like many of my readers, prior to their personal experience with this condition, they had no knowledge of the major arteries of the heart nor the possibility that they could be switched. Thanks to Houston they are now more versed in that particular heart defect than they had ever hoped to be. As an incidental benefit they now also know of the meaning of “pre-existing condition.”
The Houstons had always carried health insurance for their children and according to Blue Cross: “Our policy is that if a family has existing coverage with us, a baby can be added to the contract within 31 days without the need for underwriting to assess the baby’s eligibility.” When the Tracys submitted the bills for the surgery to Blue Cross they were told that Houston had a pre-existing condition and could not be added to the policy.
Thanks to the health care legislation if Houston’s delivery could have been postponed until September, Blue Cross could not have denied him coverage since, beginning in September, no one can be denied coverage because of a pre-existing condition. That includes new-borns.
Another feature of the new legislation is its effect on people with chronic conditions. It says that insurance companies can no longer impose lifetime caps on those with chronic conditions. For informing us how one insurance company has approached chronic conditions in the past, we are indebted to the New York Times’s Nicholas Kristof. In a column published March 21 he describes how InterGlobal (IG), an insurance company based in London, interprets that term. (IG insures international travelers living outside their home countries. It may be unaffected by the new law since it has no offices in the United States. Its interpretation of CC is nonetheless a good example of insurance policy interpretation since American policies have had similar limits on coverage for illnesses that refuse to be cured.)
One of Mr. Kristof’s former neighbors, who moved to Hong Kong with her family and was insured by IG, discovered she had late-stage stomach cancer. Her stomach was removed and that was followed by chemotherapy. It was then discovered that the cancer had spread to her intestines for which additional treatment was required. Although her insurance policy had $1.7 million coverage the insurance company did what many insurance companies do when claims are filed. It reread its policy in order to find the applicable exclusion that would permit it to deny her claims. Not surprisingly, since it wrote the policy, it found the applicable exclusion. The exclusion pertained to “chronic conditions” and that, said the company, is what the patient had. Accordingly, under the policy the most it had to pay was $85,000, its limit on lifetime claims for chronic conditions.
When Mr. Kristof asked the company the meaning of CC the company said: “Chronic means a medical condition which has at least one of the following characteristics: has no known cure; is likely to recur; requires palliative treatment; needs prolonged monitoring/treatment; is permanent; requires specialist training/rehabilitation; is caused by changes to the body that cannot be reversed.” Informed but unenlightened, Mr. Kristof asked the company to identify any disease that would not fit within its definition of chronic. Offended by the inquiry, its chief executive declined to answer and expressed disappointment at the “tone” of Mr. Kristof’s inquiry and said he would not have any thing else to say on the subject. Happily, Congress has. Although it may not prevent IG from continuing to defraud its insureds since IG operates outside the U.S., health insurance companies doing business in the U.S. will no longer be permitted to impose limits on how much they’ll pay for those with chronic conditions. That, if nothing else, is good news for those so afflicted.