Will Anyone Miss Accidents As ‘Preexisting Conditions’ and Other Insurance Doubletalk?

By Shawn Kennedy, MA, RN, AJN interim editor-in-chief

It’s interesting to have a firsthand encounter pertinent to the HCR story that is consuming the headlines. Recently, my son had a fall and dislocated his shoulder. He knew what had happened because he did it as a freshman in high school, some 10 years ago while playing sports. So he went to an ER and had the shoulder popped back in, saw an orthopedist as recommended, and went for physical therapy—all covered by his insurance plan. But all his claims for reimbursement were denied. The reason the company gave: his dislocated shoulder was considered a ‘preexisting condition.’

After my husband peeled me off the ceiling, we approached this methodically—we gathered forms, wrote letters, requested letters from the hospital, the orthopedist, the physical therapists—and appealed the ruling. After a bit, we received a response saying that they’d reconsidered and would cover the injury according to policy.

This is not a terribly compelling or poignant case, but it’s an example of the “first deny all claims” approach of some companies. Yes, it was resolved on appeal fairly easily, but why did it need appealing in the first place? I can’t imagine what patients and families with chronic illness must go through in trying to get treatment covered.

If the only thing health reform does is to eliminate the unjust use of preexisting conditions to deny coverage, it will get rid of one of the most critical obstacles to access to care.

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2016-11-21T13:18:41+00:00 March 22nd, 2010|health care policy, Patients|6 Comments

About the Author:

Senior editor/social media strategy, American Journal of Nursing, and editor of AJN Off the Charts.

6 Comments

  1. kitty kulungowski April 15, 2010 at 8:30 pm

    I have no doubt that the amount of rules, regulations, and hoops to jump through to obtain health care will massively increase, not simplify. “Pre-existing condition” may disappear from the terminology, true, but prior authorizations for meds,procedures, hospitalizations and home health care will be necessary for everything. Just think of the thousands of rules connected with Medicare, which are changed and/or added to every month—that will be the standard for everyone, not just those over 65 yrs old. And chances are it’ll be someone with a high school education making the initial decisions are allowed care, just as it is now in many Medicaid HMOs.

  2. […] Posted by ninjanurse under health care | Tags: Insurance denial | Leave a Comment  Shawn Kennedy at American Journal of Nursing writes about fighting the system when her family insurance refused to cover her son’s accidental […]

  3. Nancy Green March 22, 2010 at 8:07 pm

    I’ve been watching this sausage-making process going on for several months without refrigeration.
    But I can’t help hoping.
    I hope that small reforms will bring benefits that will show the public why universal access to health care is good for us all.

  4. Karen Kelly March 22, 2010 at 2:57 pm

    Sadly, this doesn’t surprise me at all.

  5. Peggy March 22, 2010 at 2:49 pm

    I am looking forward to this change and hopefully more to come. This is only a start, but a good one.

  6. Paul March 22, 2010 at 1:45 pm

    I thought it was pretty obvious who would miss accidents being called preexisting conditions and other insurance doublespeak: insurers. Without an excuse to deny claims, they may have to [gasp] honor their contracts.

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