Need Medical Insurance Help

[ginko]

My girlfriend(serious relationship) is having some health issues, which will require some visits to the doctor and quite probably surgery($12,000-$15,000). I've never paid for my own Insurance so I don't really know what I'm looking for. I play poker for a living at midstakes(1/2 2/4 3/6 NL) so paying 15k out of pocket would be possible but very hard for us(especially with tax's coming around again soon).


I figure you guys would know about this since a lot of you play poker professionally...

Whats the best type of plan?
What should I be looking for?
What does it mean when it says "Coinsurance: None" , Does that mean I pay none?And they pay all? Or does it mean they pay none and I pay all?(after the deductable and whatever).

Am I doing something illegal trying to get Health Insurance when I know there will probably be a $15,000 operation even though it hasnt officially been diagnosed?


Anything else?

A big thank you to anyone that can help

[BigBiceps]

Any pre-existing condition will not be covered.

[JasonK]

Coinsurance is the splitting of costs between the insurer and insured after the deductible is met. An 80/20 coinsurance plan with say a $200 deductible will require you to pay 20% of the covered costs after the $200 deductible has been paid. The insurance company will pay the remaining 80%.

You may have a problem getting them to pay for a pre-existing condition though. I'm not too familiar with that.

[mosdef]

[ QUOTE ]
My girlfriend(serious relationship) is having some health issues, which will require some visits to the doctor and quite probably surgery($12,000-$15,000). I've never paid for my own Insurance so I don't really know what I'm looking for. I play poker for a living at midstakes(1/2 2/4 3/6 NL) so paying 15k out of pocket would be possible but very hard for us(especially with tax's coming around again soon).


I figure you guys would know about this since a lot of you play poker professionally...

Whats the best type of plan?
What should I be looking for?
What does it mean when it says "Coinsurance: None" , Does that mean I pay none?And they pay all? Or does it mean they pay none and I pay all?(after the deductable and whatever).

Am I doing something illegal trying to get Health Insurance when I know there will probably be a $15,000 operation even though it hasnt officially been diagnosed?


Anything else?

A big thank you to anyone that can help

[/ QUOTE ]

Coinsurance when expressed as a percentage it means that the insurer covers that %. When it says "no coinsurance" it's kind of ambiguous but probably means they pay all.

Insurance almost never covers an existing condition, even if it hasn't been "formally" diagnosed. It's definitely illegal to buy the insurance then make a claim on an event that occured before the insurance coverage. I suspect that the insurer will be better at making sure the coverage is legit than you are at fraud, but there's always a chance you'll get away with it. But if someone makes a huge claims shortly after starting a policy the insurer will notice and investigate.

[ginko]

Ahh i see, so basically we are screwed.

[Skoob]

It sounds like your GF is looking for a fully-insured individual policy. If that's the case, the laws around preexisting conditions vary widely from state to state. Fully insured individual plans aren't subject to HIPAA (the federal reg that protects/limits preexisting clauses in group health plans).

In some states, you can be turned down entirely for chronic conditions. Anyone that has diabetes, asthma, history of depression will be turned down by every single insurer in MN, for example. But MN also has a program for people with existing conditions to get insured through a public sponsored program if they have been turned down. You might want to check if your state has a program like that. It's not Medicaid, you still have to pay for it.

Whatever you do, don't lie on the application. There's no such thing as a "formal" diagnosis. The health plan will send letters to doctors the minute a claim arrives and will ask when they were first treated for that condition. You don't want fraud charges on top of the medical bills.

The whole concept of insurance is for a large group of people to share the health risk collectively. If everyone was allowed to enroll whenever they wanted or only when they got sick, the entire system would go bankrupt. That's why these preexisting condition clauses are in place to begin with.

Most doctors/hospitals give discounts, some as large as 20% for people without insurance. If she can't get insurance, make sure everyone knows she doesn't have any and ask about a discount. You'll probably get one.

[ginko]

Thanks for the helpful responses. To be perfectly clear, *I* think she has a disease called Endometriosis, she has all the symptons. But she has never seen a doctor about this except she has talked to people at planned parenthood and they say its nothing.

Basically its her body taking the waste of her uterus and putting it in random parts of her abdominal area where they create pain whenever she is on her period. It causes a lot of pain and infertility, unless the surgury is performed to remove these "things" for lack of a better word.

So no one believes she has it because its a very commonly misdiagnosed disease. I dont even know she has it I'm just assuming because the all the pieces fit.

What happens if people dont feel well, are they allowed to get insurance? Because thats basically what it is...

[Fast Food Knight]

I would go for it. It's in your favor that she hasn't seen a doctor and has only experienced "discomfort" during her period. Every woman experiences this. Also, what does your girlfriend do? Is she a student? Does she have a job? Could she get any coverage through those avenues? Every job I've had has offered insurance regardless of any pre-existing conditions and did not require any sort of check up.

[Mr_Donktastic]

A coworker of mine just quit her job but is continuing her coverage under a "cobra" plan...she has an existing back condition which they will cover but instead of $400/month she has to pay like $1400/month.

So what I'm saying is that you may be able to find a plan than will cover existing conditions but you will pay for it.

Before trying to sign up without claiming anything I woulda seriously look into what could happen to you...it may count as fraud. It does help that neither of you have been diagnosed yet - that may be your saving grace.

Try www.ehealthinsurance.com if you haven't already.

[Fast Food Knight]

I really think it's not "pre-existing" if she's never been diagnosed, treated, and the whole condition is pure speculation.