question about coverage droppage/denial

[seekerofinfo]

What is the name of your state? calif (family/US vacation residence)

Hi,

As a US citizen currently living in Spain, I am about to take out a health insurance policy with a company (Sanitas) that reserves the right to (1) deny coverage for any claims submitted during my first year on the policy for conditions they feel could have been "pre-existing," and (2) drop me before renewal on any given year if they feel I've cost them too much. There are also 3- to 5-month waiting periods for most expenses, ie hospitalization, surgery, radiation, home care, etc.

Seems to me that they are basically ensuring I get no coverage for the first year except in very obvious cases, like accidents. What do y'all think? Does anyone know how these conditions, which conform to Spanish insurance law, compare to those for US insurance policies? This policy is fairly cheap (90 us $/month) for up to 100,000 $/year of coverage in good hospitals, with no deductibles and no lifetime maximum. . . but even so, I wonder whether I'd be better off with a US insurance policy.

I also wonder what process leads companies to decide a condition is "pre-existing"? I'm healthy, but if I were to develop a lump in my breast, say, after a few months, how would the insurance company decide whether this was pre-existing or not?

thanks for your help! I have to make my decision within a few days.

Sue

 

[kat1963]

$100,000 max per year? You can use that up in a week. Have you looked on line for USA castastrophic health insurance, aka, major medical? (it's basically a protection against financial ruin. Low payments but high deducts.)
Since you are dealing w/another country, I don't think we will be able to tell you how they determine pre conditions.
Just my thoughts, I leave them with you.
KAT

 

[cbg]

Sue - in the U.S., under certain circumstances it is permissable for an insurance carrier to determine that a condition is pre-existing, but 1.) not all companies take advantage of this option 2.) the length of time a condition is considered pre-existing is limited to one year (except in extremely limited circumstances when it can be considered pre-ex for 18 months) 3.) you have to have actually been treated for the condition in the last 12 months (some states have a shorter look back period) before it can be considered pre-ex.

I know that for group insurance, an individual CANNOT be dropped for any reason; the entire group can be dropped if the premium is unpaid or if the group drops below a pre-established minimum but other than that all cancellation options belong to the group, who are also forbidden by law to drop an individual on the basis that they are costing the group too much. I don't know if such a protection exists for individual coverage but I believe so.

Again on a group policy (I have no experience with individual policies) there can be a waiting period before coverage starts at all, but once it starts there are no further waiting periods. Again I believe this to be the case with individual coverage as well, but since I have no direct experience with them I can't be certain.

$100,000 is not much at all if someone gets into an auto accident or develops cancer.

If the policy you describe conforms to Spanish law, so be it (I know nothing about insurance law in any country but the US) but several of the provisions you describe are not permissible in the US. If you want additional detail, such as when pre-ex is permitted and when it isn't, just ask.

 

[Beth3]

seek, I know nothing about health plans in other countries but my advice to you is to look at a few other plans and talk to an experienced insurance agent before making a decision.

If you don't currently have any health insurance and/or because you're in a foreign country and subject to their rules (if any) on health insurance plans, it's quite likely there will be some pre-existing conditions limits you are subject to.

The main concern though is the $100,000 annual limit and their provision that they can drop you before renewal in any year if they feel you've cost them too much. No wonder there's no lifetime limit - with those two provisions, why would they need one? The bottom line here is that if you have medical bills of any substantial amount, you can expect to be left holding the bag for some very big medical expenses AND expect to have your coverage cancelled.

You need to look further.

 

[CIAA]

Beth3,

A U.S. citizen, with residence in Spain and a vacation house in California....what we're you doing about health insurance before?

Since the premium you cite is U.S. dollars can we assume the benefits are in U.S. dollars; if so, does the dollar in Spain buy $3.00 worth of medical care ???

In any event, when looking at U.S. policies, be sure to check out any restrictions or limitations related to "foreign residence" or care outside the U.S.

As for pre-existing disease, the U.S.' state courts have generally held that a disease "comes into existence" when it, "manifests symptoms which would cause an ordinarily prudent person to seek medical treatment or advice and for which one learned in medicine could reasonably make a diagnosis" (some minor variations by state).

You can see how this interpretation provides for a logical and practical application of the term "pre-existing".
I'm not familiar with Spanish insurance law, but perhaps you can ask an attorney over there or contact whatever govenmental agency regulates their insurance laws.

 

[seekerofinfo]

Hi, thanks to everyone for responding so quickly

First, let me clear up a bit of confusion here- my mistake, sorry about that! My policy limit of 100,000 euros (essentially same as dollars) per year only applies when I use non-approved doctors and hospitals both in Spain and in the US. The coverage on this policy has NO annual limit for medical care within Spain and/or in other countries where there are approved Sanitas doctors (including the US), as long as I stick to these and the care is deemed necessary by Sanitas, and as long as I spend no more than three months total out of Spain per year. I am not formally a resident, but we were told both by Sanitas and by a lawyer that this was not a problem.

Also..sadly, I have no vacation home in California, I was just referring to the homes of my family in calif, where I "vacation."

So it sounds like, based on what you've all said, the main difference between this Spanish policy and one in the US is that they reserve the right to drop me on any given year --which sounds like it's illegal in the US, just as I'd thought. I did actually look into the various available policies and they are all the same on this point--- unfortunately the law protects them, maybe because of the universal health care here in Spain (not the greatest system, though).

Guess I will have to take my chances for the moment- thanks again for your responses!

Sue