Diagnosis & Insurance & Employment

[leanpol]

Hypothetically, if I think I have MS and have not yet been diagnosed, given my current situation, what is the best course of action in your opinion? I am not presently working; however, I am a full-time PhD student and self-employed with limited income. I have health insurance through my husband's employer. I have not discussed MS with my doctor. I do not have a life insurance plan aside from being a rider on my husband's. Should I first seek life insurance and become gainfully employed before becoming officially diagnosed? What will a diagnosis do with regard to health insurance? I understand that if I go for an extended period of time without insurance, my next health insurance will not cover pre-existing conditions.

Also, have you heard of Klotho, a newly research medication that could repair myelin damage? Is this currently prescribed and who manufacturers it?

[MSW1963]

Depending on your current health status, any sx's you have discussed with any doc, MIRs', etc., your insurability will depend on wether you are applying for Individual Coverage or Group Insurance coverage.

Hypothetically, if you are un-dx'ed, have MRIs with lesions, history of neuro sx's within 2 yrs from employment/LTD eligibility and file a claim for LTD benefits, your claim will probably be denied based on the preexisting conditions "Look Back Period" in your medical history provision in the Group LTD policy. This is typical group underwritting practice that looks at medical history at time a claim is filed.

Coverage for Individual LTD policies, the underwriting rules are a bit different. Individual LTD Policy underwritting is completed before a policy is issued, versus Group underwriting and benefits eligibility which is determined at the time a claim is filed. Individual LTD insurability is determined before a policy for coverage is issued.

Group Health Insurance policies must comply with COBRA, versus Individual Health Insurance, because COBRA does not apply.

[MSer102]

I think its always easier if you have a job and insurance before you get diagnosed. Its better to have a job and insurance before you even start getting tested but it doesn't always work out that way. You can probably get life insurance but if you have almost anything wrong with you it will be nearly impossible to get disability insurance. You won't be able to get an individual policy and even a group policy will be pretty strict about when they'll pay.

The new healthcare reform laws that go into effect next year have done away with exclusions for pre-existing conditions so a gap in insurance coverage won't matter anymore cuz you can't get denied for pre-existing conditions. But the insurance will probably still be expensive. The law says you have to be offered a policy but it doesn't say that you have to be able to afford it. My monthly health insurance premium is as high as my mortgage payment.

[leanpol]

Thank you both! I am currently on my spouse's group insurance; however, should I get a job within the next year then it seems as though you are saying I will not qualify for group health insurance due to a pre-existing condition. Is that correct? Also, if I am able to work for several years despite being diagnosed, it seems like you are saying that I will not qualify for short or long-term disability. Is that also correct?

[MSW1963]

Group STD usually provides an income 'bridge' for insured employees to recover and return to work; or if disability continues beyond 6 months, it allows disabled employee to apply for SSDI and LTD benefits.

Group STD is typically paid for 6 months, is not usually subject to the pre-existing conditions exclusions that LTD is subject to because the benefits payment period is for a Short Term of typically 6 months.

LTD is much longer/bigger financial liability for the insurance company, with eligibility, claim waiting, and 'look back' provisions not typicall found in group STD.

Here is the typical sequence of events involved in Group LTD coverage:

Once an employee has met LTD eligibility period (eligibility period is usually one year of continous employmet), the employee is eligible to 'participate' in LTD plan, meaning you can pay permiums, put no claims are paid during the first year while premiums are paid, and is the 'waiting' period before claims are honored.

Following the 'waiting' period, begins the 2 yr 'look back' period, meaning any claim for benefits filed within the first 2 yrs from the policy effective date are subject to 'looking' back in your medical history for any sx's, MRIs, labs, doc's notes in the medical files of every doc you consulted.

Once you have satisified the 2yr look back period, your claims are no longer subject to medical review for a pre-existing condition.

The nature of the extended diagnositc process for MS makes our claims particularly subject to the 2 yr look back period in Group LTD.

A claim for a period of disability resulting from injuries due to an auto accident, auto injuries will not usually involve the look back period. Most auto accidents involve a period of recover, rehab and return to work; vs MS which is a life time illness.

[MSer102]

Group disability insurance is different than group health insurance.

For group health insurance, if the employer group is big enough there is no exclusion for pre-existing conditions. The group insurance pool is large enough that there are enough people in good health (who don't cost the insurer much money) to offset the people with major health problems (who do cost the insurer a lot of money). I don't know about small business group plans tho because the groups aren't big enough (small business ) to offset the expensive people.

But after 2014 there aren't supposed to be any denials for health insurance for pre-existing conditions for anyone - big or small groups or individual policies. My expensive policy is an individual policy. I've kept it for many years because I can't get insurance anywhere else. After 2014 I can probably change insurance companies because they can't deny me but I won't have any reason to change because it will be very expensive no matter where I go.

[MSW1963]

HIPAA health insurance regs passed in August 1996, state that you can't be denied health insurance coverage if you have not had a Gap In Medical Coverage of more than 60? days.

Even if you have a gap of more than 60?days, you can have coverage that excludes only your pre-existing condition, for a limited period of time.

I'm confusing my HIPAA and Cobra regs., but there is some overlap in the 2 sets of regs.

[MSW1963]

Forgot to add many of the regs are enforced? by Department of Labor and apply to group medical plans. There are exceptions to some regs for small employer groups, less than 50? employees.

When it comes to underwriting for group health plans, the underwriting practice is refered to as 'experience rated' underwriting to determine the premium cost.

Experience rated means that the group claims experienced for the previous year or 2 is evaluated for permiums paid versus cost of paying claims and the profit earned by the insurance company based on the group of employes.

Group plans are also underwriten at the individual leval under the group policy when a claim is filed to determine if the claim is ineligible because of a pre-existing condition exclusion.

[suziq38]

Yes, get a job that has insurance.
Order the best disability that you can pay for.
Check into Long Term nursing care insurance that allows you to be cared for at home.

I have to rely on my husband, who has good insurance through his employer.
I also have regular disability insurance.
I tried to get LT nursing care insurance, but I could not qualify based on the insurance records of my MRI's and visits to specialists.
They check everything.

Do not go looking for a diagnosis until you are ready for it.

Good question.