The Prudent Person Standard. As if "pre-existing condition" wasn't bad enough. Wow...

[sohndrsmith]

No, there is no definitive list for what a pre-existing condition is, and that's obviously no accident. I did some poking around last night trying to find something slightly specific... and I found these "Standards." That, of course include the disclaimer that it varies in each state. I expected that.

But I learned that pre-existing conditions are designated by one of two standards - or both:

1. The Objective Standard:
"Allowing only those conditions for which someone actually received medical advice, diagnosis, care, or treatment prior to enrollment to be counted as pre-existing."


This is the one that blew me away:
2. The Prudent Person Standard:
"Broader than objective standard and also includes conditions that were never
diagnosed, but where exhibited symptoms for which an ordinary prudent person would have sought medical advice, care, or treatment."

Are they freaking KIDDING?!!

Google it. Or check this site:

http://www.kff.org/

6 states use the Prudent Person Standard for pre-existing conditions, 9 states use both standards. It seems to me that the Prudent Person Standard sort of makes having the Objective Standard irrelevant.

I don't know how long this PPS has been used - but the fact that it's in use at all makes me really mad. To me, It basically says they can make up whatever they want, whenever they want if they need to bump you.

Is this term something most people know about? I don't think so....

Man it's hard to see this "industry" as anything but criminal. Good grief... I only worry that these things won't get eliminated as thoroughly as they need to be.

[snagglepuss]

1. K& R nt

[The_Casual_Observer]

2. It's clear that "insurance" based healthcare is unsustainable

[eppur_se_muova]

5. In a nutshell. nt

[eomer]

20. Actually (and actuarially), the opposite is true.

Insurance in some form is an absolute necessity. The alternative is pay-as-you-go, which will obviously work great for those individuals who are lucky and never have any major adverse event in their life or in the lives of their loved ones. Super-rich people can also get away with pay-as-you-go: there is no health event costly enough to bankrupt Bill Gates. But for the rest of us we need to spread the cost over a large group of us so that each of us pay a predictable, manageable average cost that can only be achieved by one form or another of insurance.

[Donnachaidh]

21. the TRUE alternative is a national health service which shuts out insurance completely

Just as the Brits and the Canadians have.

Insurance is a CANCER in our healthcare society, unleashed on the American public by Nixon and the HMO originators.

Insurance must be cut out of the system and never allowed to be involved with anything other than cosmetic surgery again.

The moment we allowed for profit health insurance is the moment this country started going downhill.

[eomer]

25. A national health service would be insurance.

A risk that is unpredictable and therefore difficult to manage for an individual is shared across a broad group (all citizens in the case of a national health service). The cost of the system is paid by charging (one way or another) a premium based on the average cost of providing the services. That is insurance.

[Blue_Tires]

27. at least for-profit corporate insurance....

[Fridays Child]

3. But the only way such symptoms would be documented would be if they were in your medical record.

And that means that your doctor should have recognized them and made the proper diagnosis. This holds individuals to a higher standard of medical expertise than their doctors. How ridiculous. I wonder if it's ever been tested in court. It seems like it would be easy to shoot down.

[sohndrsmith]

12. By whom? The standards are so purposefully vague that they basically have carte blanche

to do whatever they want.

How often do people appeal their pre-existing condition? I've not come across one, but that doens't mean it doesn't happen. I imagine such a challenge would involve a lot of time, money, legal counsel, so on and so forth.

How does one prove a negative, anyway? Heck, people have more rights if they murder someone. Prisoners probably get better health care than a huge number of law-abiding citizens.

Finding this darn standard really ruined my day.

Good grief I am SO glad Obama won the election. This would have never even gotten on anyone's radar otherwise. I really wish Keith (Godspeed, KO) and/or Rachel would talk about this.

These companies profit by ruining health and life. I have to take a deep breath,,, I'm too mad. : )

[LibDemAlways]

4. Seems to me anyone who knows about the "prudent person standard"

would never admit to previously having had any symptoms of a particular illness or condition. They seem to be inviting people to lie their asses off. And, of course, the reason people don't seek medical care when something crops up is that they can't afford to see the doctor for tests, a diagnosis, or treatment to begin with.

[sohndrsmith]

7. Seems to me they likely do their own checking... I wonder who would make the decision - I can't help

but imagine some non-medical person using some sort of scoring system. You'd THINK a doctor would be needed to diagnose something that you "should" have had treated some time in the past, but didn't.

Think they check accident records? Divorce? DMV? Other court actions that might mention an undiagnosed event? Things like that? It's just so unreal I find it hard to imagine its a standard in 15 STATES. Dayum...

Gotta love that Patriot Act! The law that was the death of personal privacy! I always wonder about things that may have been MIS-diagnosed... or serious but "cured". There really don't seem to be anything that even remotely resembles what is normally called: standards.

What also gets me is the fact that one has to wait longer for coverage for a P-EC. If you have a condition, wouldn't you think that NOT treating it would do nothing but make it worse? When you finally qualify, then they really have cause to deny you altogether.

This isn't health insurance. Or coverage. Or care. This is nothing short of inhumane (in my opinion). I really hope they don't find loop-holes they can hide it in... somehow, I'm not all that confident this is going to go away. It's likely one of the top modes of profit for them...

yikes.

[Go2Peace]

10. They won't get treatment even when they have health insurance.

[ashling]

6. I think we should subject the hlth ins. industry to the prudent society standard

Prudent Society would never let such a self serving profit motivated business model control the financing of the health care of its people.

:shrug:

[sohndrsmith]

8. Yes. Man, would I love to see Maddow tear this apart. That would be a very good thing.

I know you're being semi-sarcastic, (maybe not) : ) but you're absolutely right. Our very lives hinge on one thing. Profit. Not treatment. not doctors, not care, not medicine, not any of the things that are supposed to help us heal - stay functional - stay alive.

Nope - we know that the profit care regularly denies RX orders, doctors orders/treatment...

This is so disturbing. Insurance companies need another title because they insure nothing but their own profit - at the expense of humans suffering and - yep - death.

Ugh.

Excuse me while I brace for having my head explode...

[ashling]

16. being sarcastic and being absolutely right are not mutually exclusive

I hadn't thought about the Maddow angle, though. Good idea.

[sohndrsmith]

17. heh... they are most definitely not. : ) Yes, I'd love to see her

give this exposure that I certainly couldn't do in this lifetime.

I'd also like her to look at this because she has an amazing talent for figuring out and explaining things that, on first glance, are designed or worded in such a way that we assume they are something quite different from what it actually is - and then explain how and why in clear, simple terms.

I'd just hate to find out it's even worse than it seems to be.

I'm not confident about the elimination of pre-existing conditions because it seems like high risk pools are being eliminated as well. I hope... HOPE... that one reason for this is that when a new plan is implemented, the high risk pool will prove the need for the public option (or what I'd like to see: Medicare Part E - for Everyone. I've seen this term a couple of times, and I think it's a good, self-explanatory title. Be fun if lots of people sent a large E to the Capitol. Or started Adding it to every blog post - everywhere. Or something).

The health "insurance" industry's profit should NOT be based on (literally) pain, suffering and death by NOT providing "insurance" to the very people who need it most. People who are (gasp!) actually *sick*. Or might become sick. Or get injured. Or because they were simply *born* with a condition that the most perfect lifestyle and habits cannot prevent.

Seems more like death insurance to me. Ugh... (time for another deep breath). : )

[ashling]

18. How do I respond to that post? ...hmmmm...

E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E

[sohndrsmith]

23. Awesome!! K+R your post! : ) n/t

[Go2Peace]

9. It's about control. They are grooming us to so that they can harvest from our labors

Out entire lives are shaped. The same thing happens with Credit, there is no more room for experimentation, alternative living. Make a couple of mistakes and you may be shunned by the "system" all of your life.

So you have to "stay in line". Buy the right products, have the right values, never take a break from working, no smoking, drinking, keep fit and producing, don't let your mind wander.

No other country allows, and even encourages, this kind of slavery of the mind. Unfortunately, we are probably going to export it to other countries.

[depakid]

11. In practice, most anything can be asserted as a pre-existing condition, etc.

because for most folks in denial of coverage (or in rescission) situations there aren't many effective legal remedies.

[cutlassmama]

13. even if there were, they are likely in a medical crisis situation too sick to

deal with it or be their own advocates.

[depakid]

14. Yep- that too

There are also more than a few cases where those who've had portions (or all of) claims denied ended up with judgments against them- often through assignment to collections agencies.

Next, they're noticed to appear on a judgments debtors examination and for one reason or another, don't show up- and have warrants issued for their arrest.

Get pulled over or otherwise come to the attention of authorities and BAM they're in jail.

[sohndrsmith]

15. Unconscionable comes to mind, but it's far too kind. Imagine if we didn't

have the internet and access to so much information we would have never seen without it, other than the dogged few.

Imagine having this garbage continue for decades? I so hope it doesn't... even with access to info and learning about things we hadn't been privvy to doesn't mean we have the power to rectify it given the obstacles. But I have hope that we're in a far better position to be heard, at least. On some level.

If our very lives and health weren't at risk - I'd love to see huge numbers of people fire their health insurer - on the same day.

Hey, it's a pleasant daydream, if nothing else...

[LatteLibertine]

19. This is one problem with for profit

health insurance and health care driven by the same concern first. Our well-being doesn't matter unless it negatively impacts their bottom line. The object is to make as much money as you can and to pay out as little as possible. Human suffering, right, wrong, morals, ethics, all of that is inconsequential. I expect this from them. I do not expect our government to stand by and allow it to continue to occur.

If we're are going to mostly keep the profit driven system it must be heavily regulated in order to protect people from exploitation and abuse.

Personally, I'd like to see a move towards medicare for all.

[sohndrsmith]

26. Medicare Part "E" : ). Agreed. Human lives should never be measured

in terms of profit (or lack thereof). It's astounding that this system has been trundling along destroying lives and people's health just chipper as can be... I keep asking myself, what IS health insurance, anyway? I did a quick search to find a basic definition, but I didn't expect much in the way of specificity:

Insurance against loss through illness of the insured; especially: insurance providing compensation for medical expenses.
Merriam-Webster

Insurance against loss due to ill health. WordNet 3.0, Princeton University

Insurance against expenses incurred through illness of the insured. American Heritage® Dictionary

Sort of what I expected. I may be naive, but I always thought that one sought/purchased insurance and paid premiums to treat one's current or future medical expenses and to expressly to prevent massive financial loss and deterioration of health. Right?

Seems to me whatever bait-and-switch sham these entities we call "insurance companies" are basically doing the opposite:
People pay huge, unaffordable premiums with no guarantee or suggestion that the medical care they need will be paid for, *especially* if it is serious, chronic and expensive. SICK people (who really need insurance) can't get it. If they manage to get it, their premiums are twice as high... because they're sick and will incur more medical costs. Am I missing something? If insurance is not something that many people pay for so that when one of them is ill or injured, there's a larger pool of funds to cover them. I thought that's the basic premise of how insurance works.

It's as I said before; I can't get away from it. This is not health insurance, it's death insurance.

Looking at the big, general picture, Two huge entities that far and above are doing more to destroy this country and the majority her population who are not wealthy and do not have guaranteed federal insurance (paid for by the aforementioned population).

1. the financial industry
2. the health insurance industry

And both of these things are the least regulated, autonomous, self-governing (please...) entities in the nation. There are safety regulation for what can be said on television, workplace hazards, traffic and transportation, transportation, food and drugs, mailing a letter, voting... we DO regulate! But as far as our money and our lives are concerned??...

"Sorry, folks, you're on your own with that. Good flippin' luck!"

[Supersedeas]

22. the insurance industry will have their loophole and the Repigs will call it reform

[sohndrsmith]

24. Oh, don't get me going on (cough, choke) "tort reform"... n/t

[KakistocracyHater]

28. I heard if you get cancer in Japan they GIVE you health coverage, in the USA

they TAKE IT AWAY. It should NEVER be like this here.

Why are Republicans holding America back from joining the rest of the modern, most advanced, nations in the world?