MODESTO MAN’S REQUEST FOR COVERAGE FOR HIS SON REJECTED FOR 1 EAR INFECTION
Modesto Bee
Erin Richardson, a Modesto piano teacher, started shopping for a health plan for his 15-month-old son after his earnings disqualified the boy for state Healthy Families insurance.
Richardson had bought his own health insurance for six years, and his son was healthy, so buying a plan should have been easy, he thought.
He applied through a broker for Health Net‘s Simple Choice 15 plan the third week in February and received a letter from the company March 1.
Coverage denied, it said.
According to the letter, Health Net of California denied insurance because the boy had been treated for an ear infection in the past three months.
“It was sort of shocking,” Richardson said, asking what child hasn’t had an ear infection.
The earache in February was no big deal, the father said. He and his wife took their son to the doctor, who prescribed amoxicillin, and it cleared up in three days.
Last month, their pediatrician, Yvonne Brouard, tried to clear up the insurance issue for the family.
Although she hadn’t had much luck appealing to insurance companies in the past, she was certain she could get her patient qualified for coverage. But even though she insisted the child was healthy, Health Net representatives at three levels initially gave her the same answer.
“They said it was standard policy,” she said. “They were not pleasant.”
Brad Kieffer, a spokesman for Health Net of California, said Tuesday an ear infection is a factor in deciding whether to approve insurance, depending on its severity and duration. He said the company is most concerned about recurring infections and is open to receiving more information from applicants.
“It is really not so much about an ear infection as it is about the costs of health care,” he said. “We are committed to making our plans affordable in the individual market, and our guidelines accurately predict those conditions that are likely to have higher than expected health care costs.”
Brouard countered that if a common ear infection is a red flag for insurers, just about anything can delay insurance.
Young children who lack insurance are likely to go without regular checkups and miss scheduled immunizations, she said.
While the majority of people have health coverage through an employer, the self-employed and other people without benefits have to take their chances on the individual insurance market.
In California and many other states, insurers can deny coverage to any man, woman or child based on pre-existing health conditions.
Some lawmakers in Sacramento want to change that. Gov. Schwarzenegger is pushing a reform plan to require Californians to have health insurance and require insurers to guarantee coverage.
Assembly Speaker Fabian Núñez, D-Los Angeles, has a health care proposal to limit the conditions that insurers can use to deny coverage. Any legislation that is approved and receives the governor’s signature could become law in January.
In pushing for health care reform, the governor’s office has cited studies finding that uninsured people receive less preventive care, are diagnosed at more advanced stages of illness and are more likely to lose earnings because of sickness.
In addition, a 2005 article in the policy journal Health Affairs reported that lack of health insurance was a major contributor to bankruptcies in recent years, accounting for half the family bankruptcies in the United States in 2001.
Jamie Court, president of the Foundation for Taxpayer & Consumer Rights, a Santa Monica-based consumer group, said insurers are known to deny coverage for adults and children for about any condition.
The foundation obtained internal underwriting guidelines from four major insurers and made them public in January.
The guidelines revealed that insurers may deny coverage to soon-to-be fathers, pregnant women, people with asthma, acne and allergies, and patients who are in counseling, the foundation said.
Insurers look at use of common prescription drugs and the person’s occupation in deciding whether to approve individual policies. Among the occupations considered are firefighters, police officers, construction workers and migrant workers.
Court said most of the proposed legislation to address underwriting policies lacks specifics. He said he believes the governor should support legislation to outlaw such guidelines, whether or not his entire reform package is approved. Health advocates are calling for limits on health plans that charge higher premiums for people with pre-existing conditions.
“We need to force insurers to sell policies to everyone at a reasonable price and should not force everyone to have insurance until there is a price cap on what they can charge,” Court said.
PROBLEM GOING TO A NEW LEVEL
Anthony Wright, director of Health Access, an advocacy group favoring universal health care, said it has become a joke that living to age 45 or older is a pre-existing condition.
“Usually, children are healthier than the rest of the population, and examples like (the Richardson child) suggest the problem is going to a whole other level,” he said.
Brenda McCarthy, the Richardsons’ broker, said it was the first time she had seen an insurer reject an application for a one-time ear infection. She said she has seen patients refused for chronic infections because they may need to have surgery to insert tubes in their ears.
Insurance carriers often require applicants to have no illness for 90 days before approving coverage, she said.
“They wanted their son to be free of symptoms for 90 days,” McCarthy said.
Cory Bohannon, a broker for Bohannon Insurance Group of Modesto, said he first advises anyone seeking an individual plan to try to get insurance from an employer or the spouse’s employer.
He said applicants for individual plans, which can cost $350 to $400 a month for one person and $850 to $1,100 for families, must have a clean bill of health. Adults with high blood pressure or high cholesterol often are turned down.
“I had someone denied based on records their 8-year-old child had two or three chest colds,” he said. “It’s a lot more restrictive than it was five or six years ago.”
Kathryn Bolton, another pediatrician in Modesto, said she hasn’t seen as many denials lately, perhaps because so many of her patients are in health maintenance organizations.
She has had young patients denied insurance for ear infections. Asthma is a more common cause for denial, and babies who experienced wheezing from viral infections can have trouble getting insurance later in life, she said.
“I know a fellow doctor who won’t use the asthma diagnosis because he had a number of patients who were blacklisted by insurance carriers,” she said. “He writes ‘reactive airway disease.’ ”
Getting disqualified for insurance definitely affects health care for children of any age, Bolton said. Often they don’t have regular health screenings and wait for any illness to get worse before seeing a doctor.
Because of the more frequent occurrence of sexually transmitted diseases and drug and alcohol abuse, the American Academy of Pediatrics recommends yearly physicals for teen-agers instead of once every three years.
The efforts of their family doctor finally paid off for the Richardsons.
Last week, Brouard said a Health Net representative left a message on her voicemail saying he didn’t understand why an underwriter had considered the ear infection an uninsurable risk. The boy was granted coverage as of Sunday.
She said it’s a hollow victory for the uninsured, and believes Health Net gave in over the threat of media exposure.
Brouard has lost other patients who were denied insurance for what she considered minor health issues, despite calls and letters she wrote on their behalf.
One had a large birthmark, called a hemangioma, which is caused by abnormal blood vessels in the skin. The purple marks can bleed and infections can occur in the blood vessels, but the redness starts to fade after a year and may disappear by age 7.
“If I didn’t have a proactive doctor, I would have risked a lapse in coverage,” Erin Richardson said. “This is the only way I have to pay for his immunizations and regular checkups, let alone any other things that could develop.”
——————– SPEAK UP ——————–
Have you had medical insurance problems? Share your story at www.modbee.com/speakup.
See the letter sent by the insurance company at www.modbee.com.
Bee staff writer Ken Carlson can be reached at [email protected] or 578-2321.
