Question about medical insurance premiums

[canetoad]

Hypothetical: You have paid premiums for years without claim. Then you find yourself ill and the insurance fund finds one of those non-disclosed conditions, something you, yourself didn't even know about.

Are they compelled to refund the monies you have paid into the fund?

[Bombtrack]

1. you know the rules and so do I

http://www.youtube.com/watch?v=RSsJ19sy3JI

[canetoad]

4. Actually I don't

I'm aware that very few people have taken on an insurer and won. I'm asking because I want to know.

[Bombtrack]

6. A full commitments what Im thinking of

You wouldnt get this from any other guy

[Horse with no Name]

2. No.

BUT unless you have been diagnosed with a condition...they can't hold it against you.
For example.
If you are 6 months pregnant and haven't had a Health Practitioner TELL YOU (or your representative) DIRECTLY that you are pregnant, it can NOT be considered a pre-existing condition because they are the ONLY ones that can render a diagnosis.

[RB TexLa]

7. Except that a "prudent and reasonable" person would have had that condition checked out

prior to the 6 month time.

[Horse with no Name]

11. *unless* they know the loopholes

and are "waiting it out" until their health insurance kicks in.
I've done it before. I am very familiar with this loophole.

[canetoad]

10. Ok, I get the point about diagnosis

But just say someone had - lets say, (not being a medical person I'm finding it hard to cite an example) some kind of tumor since birth, but it did not manifest itself in any way and was never diagnosed.

Then, after shelling out for insurance for a few years, they break their leg and in the process of hospitalization this tumor is discovered. In such a situation would all health cover be cancelled? If so, would a refund occur?

[RB TexLa]

14. Neither. If a condition is unknown and a "reasonable and prudent" person would not have had it

checked it is not considered non-disclosure.

The black and white example is like you said a tumor that is somewhere unknown and a baseball size growth under one's arm. If you buy insurance and the next month go and get the baseball size tumor checked they are going to say that a reasonable person would have had it checked before and that you were trying to defraud the insurance company. However the situation you described would be covered.

[uppityperson]

15. No refund, no. You were covered, you just chose to not use the coverage.

Whether they can or cannot cancel depends on the sliminess of the company. I think it used to happen more, think there are laws against it, but again they can find a way. Like, say, jack the rates up to where you can't afford it.

But no, no refund. If you didn't use the insurance coverage, oh well. There is a plan where people put money away to use for health care, with some employers also adding into it. I think you might get that back if you quit, but not sure. Can't remember what it's called either, just the general idea.

[Sgent]

27. If the insurance contract is recinded

you can get a refund.

[uppityperson]

29. If you pay ahead (which is normal) and policy is stopped, you get money back

for the months you paid ahead. But you don't get money back for the months you had an active policy but didn't use any of it actively (didn't go to doctor for instance). Is this what you mean or can you get more back? Thanks.

[Sgent]

30. Nope

If they rescind a policy (at least in states I'm familiar with), the policy is completely null (never existed). In that case they should refund all premium's paid, less any payouts they have made on your behalf.

Note that most individual insurance policies have a point where they can no longer be canceled (rescinded), commonly 2 years.

[Horse with no Name]

16. Then you are basically screwed

Congenital (which is the term you are looking for) anomalies are sometimes excluded in your policy--especially in personal policyholders. Generally the Group policies CANNOT exclude it.

There is a (always) a clause that protects the insurance companies against refunding premiums.

The only healthcare that will be denied is that which is directly or indirectly related to the congenital malfunction.

Refunds will never occur.

I am sorry you have had to endure whatever it is that you have--even though you haven't said.
I've gone against insurance companies and it is very difficult to fight them.
Good luck.

[canetoad]

22. awww, thank you, but no

I honestly have not been in this situation or known anyone who has. Just trying to get a deeper undertstanding of your health system,

[uppityperson]

3. Health insurance is legalized gambling. A lawyer might help.

Medical insurance companies exist for 1 reason, to make lots more money then they pay out. Start there and it helps. A lawyer might be able to help.

[canetoad]

5. Sorry if you misunderstood

I am not in this position. In fact I'm half a world away, guarded by a national health scheme, just trying to get a firmer grasp on the situation you are facing.

[uppityperson]

12. I missed you were opposite of me. Not pay you back, no.

There might be a way to make them pay for it, using lawyers, but not pay you back no. That is how it goes. You give them money, thinking that if you get sick and need it, they will pay for it. They take your money, thinking if they can deny you services they can keep the money.

I have friends that put a couple hundred aside every month to pay for future health care needs, and then will go into the whole also. I hav friends that pay for checkups, minor lab work, massages and chiropractic regularly to stay in shape so they hope they won't need major health care. Had a couple go into debt tens of thousands on this plan. Now they have insurance.

If you do have a medical condition, you do NOT want to EVER go off insurance for even a month because then they will collect money and not cover "pre-existing conditions", but you if you have had insurance continuously, then there is no pre-existing non-covered condition, even if you switch insurance companies. They cam make you wait 3-9-12 months. It sucks. Have to keep paying in, just in case.

Also, if I were to get bloodwork, labwork, done, the lab would charge me personally (example) $325. If I have insurance, insurance would send them (example) $87.12 and the lab would erase the rest. This makes me angry also, seems they are charging insurance 1 rate and private pay another, which is against the law, but they get around it.

[canetoad]

19. That makes it clearer

So the labs can just write off over $300 and accept whatever the accepted rate is? Some creative accounting has gone into that one.

Continuous cover is another scam. Are medical expenses dealt with on a claims made basis? Assuming full disclosure at time of acceptance of cover, are they forced to deal with circumstances that arise during the period of cover or can they worm out of that too?

[uppityperson]

21. Not sure what you mean, getting late here and my mind is slowing down.

Yes, those accepting insurance write off what they don't collect. Example, I bill $60, collect $59, write off $1. For people paying at the time of service, I give a $10 discount, meaning they pay $50. But then I am ethical.

Not sure what you mean with the rest. Getting tired. If you explain a bit more, I'll try to reply, then off to bed.

[canetoad]

23. It's friday afternoon

Beer-O-Clock.

Thanks for your patience. I'll get back to it another time.

[Rosemary2205]

25. Most payments are contracted in advance here.

Basically the lab and the insurance companies they accept have already contracted the charge and the payment in advance for each particular procedure. With primary care, quite a few insurers also negotiate capitated rates. Say we are talking Cigna and Laureate Medical Group. Laureate Medical negotiates $3000 per Cigna insured per year. They'll make money on some patients and lose money on others.

[BlooInBloo]

8. LOLOLOLOL!!!! That's a good one!

[RB TexLa]

9. There is a non contestable clause in most health insurance contracts

after two years (most states) the insurance company can not deny a claim for non-disclosure.

I'm pretty sure it is in all. This is done by state law, it might vary by state as to the time frame but two years is pretty standard.

[canetoad]

13. Thanks for that

I never misunderestimate the depths to which insurers will sink in trying to deny liability.

[uppityperson]

17. Do you mean you have to argue with them for 2 yrs, or that you must file withing 2 yrs?

Or if you haven't known for 2 yrs? I don't understand. Thanks.

[RB TexLa]

18. After the policy has been in force for two years. This is primarily in regards to individual

issued policies.

[uppityperson]

20. They must figure any pre-exisiting would show up within 2 yrs?

Or the insured would've gotten it checked. Got it. Thanks. I am a insured person and a health care provider who deals with insurance companies. Legalized gambling and they hold the best cards.

[Rosemary2205]

24. State laws govern this and vary from state to state.

Basically the way things often work for people buying individual policies is that their insurance company will drop them for any nitpicky reason whatsoever after taking the money. The person's only recourse is usually to sue, which takes a lot of time and high paid insurance lawyers know how to drag things out until the person either goes bankrupt or else dies of their illness.

Some states have strong laws governing how insurance companies conduct themselves. Georgia, though less that perfect, does a fair job of keeping the smackdown on insurance companies. Even so, it is not uncommon for patients to get caught between an insurance carrier and a large health providing organization squabbling over their payment contracts.

[canetoad]

26. And we all know how well motivated

to embark on legal action a seriously ill person would be. I'm sure the actuaries have examined the odds.

[izzie]

28. I spent almost 6 years in college and I can not understand the bill

I just had to go to a doctor and I do not think that med-gap or medicare will pay but I am not sure if that is what it said. I am going to be sicker trying to figure out the bills I am getting than what I went for. Old age and I pay about 200 a month for health ins. and they never pay for a thing as of 10 years under thing GD thing. I also pay for dentist and glasses out of pocket. I have to be crazy paying for something I never can use as they will not pay. My annual check up is now every 7 years.