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Lung cancer, heart disease or stroke.
Suffer those or other serious health problems and you may be out of luck landing individual insurance when you need it most.
What about asthma or a bad knee? Might get covered for everything — except those conditions.
High blood pressure? You could find coverage but might pay more for it.
Those are potential problems facing people with pre-existing medical conditions.
But relief could be in the works. Key bills in Congress would prohibit insurance companies from denying coverage to people with such health problems.
Claims that there would be “death panels” and the hotly debated public option insurance plan have drawn more attention as Congress wrangles over health care.
More quietly, and backed by everyone from the president to the insurance industry, provisions on pre-existing conditions have found their way into the three main congressional bills.
“It's a sign of how big a problem it is for Americans right now,'' said Cheryl Fish-Parcham of Families USA, a nonpartisan consumer advocacy group.
A 2007 survey by the Commonwealth Fund, a health care foundation, showed that among those who had tried to purchase individual insurance in the previous three years, 36 percent said they were turned down or charged a higher price because of a pre-existing condition.
Dave Wythers of Fairmont, Neb., knows the challenge of buying an individual policy.
His chest felt heavy as he ate breakfast one day. A test showed artery blockage. Doctors inserted a metal mesh tube called a stent into his arteries to improve blood flow and put him on medication to lower his blood pressure.
About a year later, in 2005, he left his job at a community health center to work as a self-employed mental health counselor.
When he applied for individual insurance, he was asked about any heart problems. The insurance company denied him coverage because of the heart procedure.
Wythers, now 55, was stunned. Other than the blockage, he was in good health. His doctor told him the procedure fixed his heart problem.
Wythers emphasized those points when he asked the insurance company to reconsider. The company said no.
“It's ridiculous,'' Wythers said.
Insurance denials for pre-existing conditions also affect those with insurance.
Hospitals caring for the uninsured can pass along those expenses to insurance companies in higher costs for medical services. Insurance companies might pass those costs to consumers through higher premiums.
The insurance industry backs the congressional provisions on pre-existing conditions as long as all Americans are required to purchase insurance, said Robert Zirkelbach of America's Health Insurance Plans, an industry trade group. The three bills require that all or nearly all people purchase insurance.
Zirkelbach said if insurers couldn't deny coverage for pre-existing conditions, people would wait until they were sick to purchase it.
Requiring everyone to purchase coverage would solve that problem, he said. And more young, healthy people would be buying insurance — and not making claims — whichs would compensate for the added costs of those with pre-existing conditions.
Provisions to require health insurance appear to have solid support in Congress as long as they are coupled with bans on denying coverage, said Keith Mueller, a public health policy researcher at the University of Nebraska Medical Center.
Mueller said it's too early to know whether insurance companies could make money off the mandated insurance requirement.
Wythers eventually received coverage through the state's high-risk insurance pool, an option for people denied coverage because of a health problem.
He pays a premium of $442 per month and has a $5,000 deductible. The program's premiums generally run 35 percent higher than the average premium for private individual insurance.
Iowa offers a similar high-risk pool.
A key goal of the bills in Congress is to provide affordable health coverage for Americans, but it's too early to determine if Wythers would actually pay less for insurance if the legislation were approved.
Pre-existing conditions generally aren't a problem for the 60 percent of Americans insured through a job, and only five to 10 percent of Americans have private individual insurance now.
But that number could grow, said Dr. Richard O'Brien of the Center for Health Policy and Ethics at Creighton University.
An increasing number of employers, particularly smaller ones, are dropping group coverage because of the cost. And it's becoming less common for employers to offer health insurance to retirees, leaving them on their own if they are too young for Medicare.
Jeff Ingraham, an independent insurance broker in Omaha, said he has seen more people looking for individual insurance over the past two years, partly because of job losses.
The questions insurance companies ask surprise some clients. Applications can list more than 100 ailments, from abdominal pain and bladder disorders to depression, infertility, sleep disorders and ulcers. “It's head to toe,'' Ingraham said.
Jesse Patton, owner of a Des Moines-based firm that helps people land individual coverage, said people get frustrated when they discover they can get coverage for everything but the one problem they need it for.
An insurance provider might say it will cover everything but the right knee, left index finger or a even a specific spinal disk because of a prior surgery.
Blue Cross Blue Shield of Nebraska, a major health insurer in the state, accepts most applicants for individual coverage but denies some based on health conditions, said Jerry Byers, senior vice president.
He said the company does not automatically deny coverage based on a list of ailments. The company looks at the specific circumstances and the severity and timing of the illness.
A person who had cancer but is in remission might get coverage. A person diagnosed six months ago might not, he said.
Patti Meglich, an assistant professor of management at the University of Nebraska at Omaha, said coverage denials can protect others insured by a provider. If an insurance company covers too many people with expensive claims, those costs can get passed to other customers in the form of higher premiums.
“They (insurers) don't want to take on undue risk,'' she said. “They are not social service agencies.”
sContact the writer:
444-1122, michael.oconnor@owh.com
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