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Denied health insurance for seeing a doctor? 

Medical malpractice case ?  Are medical insurance companies guilty of medical malpractice at times when denying insurance based solely upon review of medical records?  Who is reviewing those records and are they medically competent or are they engaging in medical malpractice or medical malfeasance?

Denial of health insurance coverage is sometimes truly surprising.  I have been trying to purchase a health policy for both my wife and myself.  I have learned quite a few things and have portrayed my experiences here.  Suffice it to say as of Nov. 2003 my wife has a health policy and I do not.  It is not your doctors fault, but you may always want to speak to your doctor hypothetically regarding any malady you may, or may not, have that can affect your future insurability!  Watch what goes on your medical record!  Make sure anything written is a true diagnosed medical problem and not just a concern or worry on your part.  To get insurance you have to sign an agreement allowing your potential insurer access to your medical records.  If they decide to look at your records they most certainly will find a reason to deny you insurance, especially with the current financial market, even after the recent recovery ( 11/5/03 ).  What's funny is they apparently never check the medical records of applicants that report no significant medical conditions.  This is supposition on my part but I am fairly certain the insurance companies involved never checked my wife's medical records.  In the policy my wife did receive there is one condition that will not be covered for two years, of course there is no discount for this reduced coverage even though the insurance company has reduced its risk exposure!

Medical malpractice case ?

More to follow, my rejection letters and how I feel the insurance industry is possibly guilty of misinterpreting medical records and by doing so committing medical malpractice themselves; they are interpreting medical records they must have the appropriate skills, and credentials, to do so!!!  EHealthInsurance has offered to find other carriers for me, but I am confident the price will be high, so I have not looked into it yet.  Perhaps one day a medical malpractice lawyer will read this and pass on an opinion?

Medical Malpractice ?  The first health insurance policy rejection letter.

My first health insurance application was denied in February 2003.  The insurance company involved provided three reasons for denial.  During a phone conversion about this letter which took two months or so to extract from the company, I learned at this time that any preexisting condition was sufficient for denial.  I believe this company was not truly capable of understanding the medical records involved ( medical malpractice case?).  Of the the three conditions two of which are very common, while technically I have the conditions, I am also completely and successfully treated for these conditions through medication, diet, and exercise.  Both of the conditions are probably hereditary in nature and in my age group I believe many, many, people in the country are being successfully treated for these two conditions.  Please forgive the fact I am being so vague about my conditions but I guess I am still attempting to acquire health insurance.  Anything I say here could certainly be misconstrued by the insurance "under writers"!

First insurance company attempts to mask and delay documentation of reason for denial.

The staff at my doctors office was kind enough to give me a copy of the denial letter from the insurance company, and my doctor had no problem with this.  When I first asked the insurance company to document why the underwriters rejected me they explained to me "we are unable to disclose the reason for the denial to the applicant, due to policies regarding confidentiality".  I think perhaps they would like the issue to go away, and perhaps they are fearful in the long term of a medical malpractice lawsuit.  But they would send the following letter to my doctor.  I have removed the doctors name, insurance company, my conditions, and my DOB: date of birth.

The context of the first denial letter:

February 28, 2003
Dr. ------ -. -----
---------- --------
-------- Box -
---------- Trail
----------, -- -----
RE: Robert Matheson
DOB: -------- 
Dear Dr. ------:
Recently your patient, Robert Matheson, applied for -------- Health Plan Insurance.  Individual applicants are required to pass medical review. If the applicant does not pass the medical review, based on information obtained from their medical record (which is not always revealed on the application), we are unable to disclose the reason for the denial to the applicant, due to policies regarding confidentiality of the medical records and the possibility of disrupting the physician/patient relationship.
We will reveal this information to a physician, with the applicants written request, and allow your discretion to discuss this information with the applicant. Robert has requested this information to be sent to you.
Reason for insurance denial:
Medical conditions of --------, -------- and -------.
The Staff of ---------- Health Plan
10/30/01 REV

You can see from this letter that I should never have received a copy.  The onus was left to my doctor to explain the insurance companies rejection!  In a way they tried to make it look like my doctor was actually involved.  He had no chance to interpret his own records for the insurance company.  Again who at the insurance company is making these medical diagnosis and decisions, I will bet it is not a doctor?  Medical malpractice case?  Medical malfeasance?

MALFEASANCE - The unjust performance of some act which the party had no right, or which he had contracted not to do. It differs from misfeasance, and nonfeasance.

MALPRACTICE - a wrongful act that the actor had no right to do; improper professional conduct.

My doctor and I discuss the reason for the first denial.

My doctor initially thought this company had infringed on my privacy, he was not aware that you, the insurance applicant, must give authorization to the company to copy your medical records just to have a chance to get a policy.  The third reason for rejection by this first company was a complete misunderstanding of what my doctor had written.  My doctor had written down what possible courses my as yet undiagnosed third condition could lead to.   In speaking with the company this misinterpretation of the third condition did not matter cause I already struck out with the first two conditions.

The second health insurance application denial

I was certain this second company would give me insurance.  Here I was going for a high deductible policy, which should drastically reduce the companies risks and administration costs.  During this process the company did have difficulties acquiring my medical records.  And in fact without telling me they gave up trying.  Only when I wrote the broker did I learn of these difficulties and the onus was on me to fix it.  Turns out the records made it in time for the review.  During this delay this second insurer, without contacting myself or my wife, decided they could go ahead and just insure my wife and add me later.  I learned of this when my wife received her insurance "package" and I get nothing!

The context of the second policy denial letter:

------ ---- Insurance Company
October 17, 2003
-- -- -- ----
------------, -- -----
Subject: ID Number --- --- ---
Dear Mr. Matheson:
We have received the medical information we requested from Dr. ----- ------.  ------ ---- is a preferred risk health insurance company.  As such, our underwriting standards are very strict.  Although not everyone qualifies for coverage with ------ ----, this does not mean that other insurance companies would be prohibited from offering coverage.   We are unable to provide coverage for Robert because of his symptoms last December of slurred speech and word loss of uncertain etiology. We thank you for the interest you have shown.

M------ G-----
Underwriting Department
------ ------ Insurance Company
-------- ------ Drive
----------- -------- --------
62767 NREVEW-2

Frankly the wording of this, especially the sentence fragment: " this does not mean that other insurance companies would be prohibited from offering coverage" is difficult to understand.

My third condition.

I am somewhat paranoid of conditions both my mother and father have had.  My mother has had a heart condition since childhood.  This weakened heart has probably at times been a source of mini-strokes and lack of oxygen to the brain.  An example might be having a numb finger or toe for a year or two which then recovers.  These mini-strokes may have propagated into her speech centers.  While my mother is cognizant she has varied difficulties expressing herself with the spoken word.  She has speech difficulties.  I occasionally slur a word, I think many people do, but I am also hypersensitive about any speech problems I might have.  I also believe the cause for this may be as simple as an excessively dry mouth!  So I expressed this concern about my future well being with my doctor and basically I believe my doctor made a note to himself to carefully watch for signs of this potential condition in the future.  But the company read this document and seemed to infer I was having significant difficulties now, which is not the case.  In addition I reported to my doctor signs of word loss, but to be frank in observing co-workers, (even younger coworkers), my frequency of word loss is no higher than typical, but again, because of my mother's condition I reported this to my doctor.  Again I feel the insurance company has misinterpreted my doctors records.  Medical malpractice case?  Medical malfeasance? 

The application process.

I was totally honest on my application.  What's truly annoying is that people that are dishonest probably fly right through the approval / "underwriting" process.  My impression from my experience is that if there are virtually no medical conditions on your application your records will never be pulled for review by the company, bam, you have insurance, you take the risk that the company discovers you may not have disclosed something but what is the likelihood of this.  This is like the auto insurance companies that did not take the time to check whether you owned the car you were insuring.

Once you are denied the first time, you are in big trouble.

You have probably given the insurance company the right to share this denial and the reasons and probably even your medical records with other companies.  You will find on every application the question; "Were you ever denied coverage in the past?  Please cite the reason".  But in some cases you have to pry the reason out of the company and then it can be as simple as we are denying insurance to anyone that is not in perfect health now.  But now you have a rejection recorded and the insurance companies may share this information!  And did you know about the MIB, the Equifax of medical records!  Here is a page where you can request your MIB records.  The companies may share your health information through the MIB; here's a quote from the application page;
"There is a charge of $9.00 for each request for a Record Search and Disclosure. This charge only partially covers MIB's costs in providing Record Search and Disclosure and correction services".
This company acts as if it is providing me a service that I should pay more for.  If I had my way I would prefer this company did not exist.  They insist so many people are trying to defraud the insurance companies, but it is probably only those who will be denied a policy.

Before I applied for these records I did write this company an email asking, does the MIB membership consist of either of the two insurance companies to which I applied.  You could pay $9.00 just to find out there are no records!  They did answer and yes one of the two companies was a member.  I may have used the wrong name for one of the companies, I wasn't sure what to call it because it is a health organization that does offer HMO like insurance.

Some background

I am in fairly good shape, in my fifties, I like to ski, alpine ski, and even mogul ski.  I pursue many projects on my property and in the last few years I have been doing many things by hand versus renting power tools like trenchers etc.  For various projects I have dug trenches with my pick, moved tons of stone with my shovel and even more tons of topsoil, mulch, etc.  So while I do not go to the club and exercise I do get a good cardiovascular workout.

What next?

I guess this mogul skier is uninsurable, I am uncertain what I will do next.  For now my wife is insured, we are only paying a little less than we were supposed to pay for both of us!

The insurance companies have provided no means of appeal.  They have not contacted me or my doctor regarding their interpretation of my medical records.  They have basically made a misdiagnoses without having ever seen the patient or the doctor involved.  It seems to me to interpret medical records you must have a doctors credentials.  If you misinterpret these records and cause harm (lack of proper insurance), is this medical malpractice, practicing medicine without a license?  Perhaps somebody with a medical, legal background can consider this and write me?  Perhaps a medical malpractice lawsuit or medical malpractice class action suit?  Conclusion below:

What can be done?

One thing I have done is raise my medical coverage on my car insurance.  Certainly an accident could be a major source of medical bills and these can be paid by your car insurance.  As I said before EHealthInsurance has offered to find other insurers, but I am sure they will charge more than I am willing to pay or may not be a high quality company so when you make your claim they go oops we cannot find any money.  Plus I get tired of shelling out a loan to these companies of one quarter's premium.  Also the delay in one application was caused by a cap in the fee the insurance company would pay for copying medical records.  They had a maximum of $30, and the courier service or copying agency wanted $50 prepaid, apparently this is unusual.  So I shelled out $20 to make up the difference for no insurance!  And probably now I have a record at the MIB!  I will probably order this to see and add to this article later.

Risk Pools

One method of obtaining medical insurance.
Healthinsurance.org Risk Pool info   Risk pools in many states, not mine at this time.  I will not be looking further here because my state does not participate.

Health Insurance Brokers

For my second health insurance application I used EHealthInsurance.com, while my wife did receive a policy I did not, but throughout the process EhealthInsurance did everything possible to expedite and gain approval by the actual insuring company.  I was pleased with EHealth's performance, help, and support.  They have an excellent product comparison guide.  What they seem to do is have you fill in their standard application.  This can easily take half an hour, you really need dates and times of discovery of conditions or surgeries etc.  Doctor names, addresses, phone numbers.  Once this standard form is filled out, when you are ready to submit your application apparently EHealth attempts to automatically fill out the actual insurance companies forms.  There were some minor transcription errors and a few days later I had to review some of the details on the phone with the actual insurance company.  So I would still recommend giving EHealth a try:

Conclusion of Medical Malpractice case, health coverage denials

Well I hope all this complaining at least can help those that are just starting this process.  Be careful how you express your concerns to your doctor, and how your doctor documents these concerns.  My doctor added clarifications to his records after we discussed the first denial.  I will be discussing the second denial with him in the near future.  I would love to hear opinions about a medical malpractice class action suit against health policy issuers; I am probably crazy.


Sources and References:

US General Accounting Office report on Medical Malpractice premiums 
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BHT Created: 05 Nov 2003

BHT Revised: 03 Apr 2017


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Copyright 2003-2016 Robert Matheson.  All rights reserved.  Email Bob at BobsHowTo.com - . 

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