The sides of the "heads we win – tails you lose" coin.

The sides of the “heads we win – tails you lose” coin.

I reported a few weeks ago that on May 31 I’d experienced an atrial fibrillation episode that sent me into the Emergency Room at Eisenhower Medical Center in Rancho Mirage, California. An EKG was run, and upon reading the scrolled sheet the attending physician asked whether I’d ever been diagnosed as having an irregular heart beat.

Quite truthfully I responded that I had not.

Again, that was 100% a truthful statement. For the purposes of this discussion, let’s just paint a completely confected fictional example. Let's suppose that ten years prior to this May 31, I was 53, not 63, and I was sitting with a health insurance representative, completing a health insurance application. Having been one for a decade and one-half, prior to my retirement a few years back, and licensed in California, Florida and Nevada, and appointed by every major player, I can tell all who have never applied for health insurance that is not employer-sponsored that the questionnaire is lengthy and extraordinarily probing. (“Have you now, or to the best of your knowledge, ever had . . .?” Ever is a l-o-n-g time to remember stuff that you’re going to, under penalty of perjury and the insurance fraud laws of your state, sign your name to.)

Although not completely germane, I can also tell you that, if a single-only, 53-year-old male applicant for non-group medical insurance did not have a heart condition previously, seeing the rate would likely prove a trigger for serious cardiac trauma. I haven’t seen a rate-chart for a “preferred” applicant in three-plus years, but it’s at least in the $1,500 per month range. Nah . . . That’s too easy. You do the math for the annual premium, then check YOUR own budget.

Point 1 of Insurance Law: Any material misrepresentation made by an applicant on an application for insurance, at the insurer’s sole option, will render the insurance contract voidable.

Point 2: For a statement to be “material” only requires that it be one that would have provoked the insurer to come to a different decision, whether as to approval of the contract, or to any element in the contract; what’s covered, what’s not, under what conditions, and the premium rate it would have charged, had it been aware of the condition, etc.     

Point 3: It is not necessary that the misrepresentation be one willfully made by the applicant. Under the “prudent person” rule, all that is sufficient is that the applicant could have known (via adequate and/or thorough physical exams by competent medical personnel), or should have known (family history, etc.).

Point 4: No one with a completely healthy heart has ever had a sudden heart attack. That the patient had never experienced any active symptoms prior to the cardiac trauma overlooks the fact of what a symptom is; something one can feel or see, for example. By definition then, heart trauma depends on some level of a preexisting condition. When getting word that one of its subscribers has been rushed to a hospital with a serious heart problem, the best outcome, from the insurance company’s perspective, is that the patient quickly does the right thing, and dies. If the patient lingers days, maybe weeks or longer, the accruing tab will very often pass six figures into seven. That’s a lot of incentive for an insurance company to deny a claim based on a preexisting condition that was not disclosed on the application for insurance.

A heart condition is not the only one where claim denial subsequent to issuance of a policy occurs. It is the example I used because I felt it is the one that might be most easily and vividly understood by everyone.

Now I want to go a step farther, to get as far into the core of your emotions as possible. A 51-year-old man is one thing. Sad, perhaps even tragic. But let’s say, instead of that middle-age fellow, it was a child, let’s say it was YOUR CHILD! I don’t know whether denying a claim on a child occurs every day, but I’d be willing to bet a body part that it does take place every week; somewhere in the United States.

This issue, healthcare reform, is so overwhelmingly critical to the very survival of this country that sitting on the sidelines, not being adequately interested and informed, is as despicable a posture as anything else I can conjure.  

Those who know an associate who is preliminarily opposed to any level of federal government involvement must confront that person, to demand to know why they are opposed.

Arguments rebutting “because it’s too expensive”:

First, define “expensive.” The nonpartisan Congressional Budget Office has estimated, and the Obama White House has expounded, a cost of $1.6 trillion, over a ten year span. Under our current for-profit, private health insurance scheme the US is spending around 18% of every penny, dime and nickel that composes our GDP, a percentage that will before long, unless the arch of the trajectory is reduced substantially, reach 34%. Neither this country nor any other can survive under that burden. Contributing to the current costs are an insurance industry weighted down with administrative costs around 30%; that’s 30¢ out of every $1.00 in premium paid buying not a single cent of care for anyone. By comparison, the admin figures for Medicare and the VA are 7% and 5%, respectively. Some folks are getting exorbitantly rich while not returning a value commensurate with the prices being paid.

Disclosed recently by the Insurance Institute was the “average” annual per worker health premium employers are paying: $10,000. Few employees have even a slight clue that that’s one of the most compelling reasons US employers are confronted by the absolute need to cut payroll, cut wages, hold wages static, cut benefits, or all the above. Here’s a tool that might prove helpful; the Rule of 72. It tells how long it will take to double a base figure, given an established rate. For several years the rate of premium growth has been in the 15% range. Take that 15% and divide it into 72. The result is 4.8 years. In other words, that $10,000 annual premium will be $20,000 in less than five years! You’re the employer, what would you do? Now, how will you define “too expensive,” when it’s your job and benefits that are on the line? Never forget this turn on Newton’s First Law of Motion: If nothing is changed, nothing is going to change.

 1  |  2