National health reform will strengthen protections for Massachusetts consumers by eliminating lifetime caps, financial restrictions on how much an insurance company will pay for care. Under current Connector regulations, insurers may cap benefits for students and young people, and they may impose lifetime limits on benefits for “non-core services.”
This will be reversed under national health reform. Eliminating lifetime benefit caps is one of President Obama’s 8 “Core Health Insurance Consumer Protections” he’s insisting be a part of national reform.
Why is this important? Here is one mother’s story:
There are few things that seem more patently unfair to me than being denied health insurance coverage when you become too sick and too expensive for the insurance company to want to continue to insure. Lifetime caps enable a health insurance company to deny any further coverage once an individual has “cost” the insurance company a certain amount of money.
My family knows the injustice of lifetime caps first-hand. When our second child was diagnosed in utero with Hypoplastic Left Heart Syndrome, a serious congenital heart defect in which the left side of the heart fails to develop, we had an 80/20 PPO insurance plan with a lifetime per person cap of $1 million. Before our child’s diagnosis, this seemed like an incredibly high maximum and a number that we would never be in danger of hitting. However, in order to save our son’s life, his doctors performed 3 open heart surgeries – the first at 3 days old, the second at 6 months, and the third at the age of 2. In addition, he has undergone several cardiac catheterizations, many inpatient and outpatient tests and procedures, and more trips to doctors and to the emergency room than I could begin to count.
By the time he was 4 years old, we were already halfway to his lifetime cap. What would have happened if we had hit that lifetime cap? Our insurance company would have terminated our child’s medical coverage – not for 6 months or a year but permanently.
We have been incredibly fortunate not to hit that lifetime cap for two reasons. First, our son exceeded all medical expectations and had relatively short hospital stays for each of his surgeries. In addition, feeding tubes, in-home nursing care, and other therapies that were expected were never needed. Additional surgeries and complications we were told were quite possible were not required. Second, we had the opportunity to switch to a new insurance plan without a lifetime cap shortly after our son’s 4th birthday. We were incredibly fortunate on both fronts.
Why speak out on this issue when we were not actually confronted with losing our child’s medical coverage? Because we came incredibly, frighteningly close to that happening. Because we look at other families who have faced that reality and know that it could have been us. Because lifetime caps are unjust and devastating to individuals and families. How can we allow insurance companies to tell their paying customers – “we guarantee you coverage but only up to a point, and if and when you get really sick, we can cut you off”?
National health care reform can help Massachusetts residents so that other families don’t have to live with the fear we did that our child would outlive his insurance coverage. I imagine families putting off tests and life-saving procedures, rationing needed medications, and waiting to act on new or worsening symptoms because they are trying to cut medical costs. Believe me when I say that living with a life-threatening condition is frightening enough without worrying about maxing out your insurance coverage.
Diane
American Heart Association Volunteer, and Affordable Care Today Member
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The whole problem with caps is that they do seem like large numbers, but most of the population will not have any direct idea as to the cumulative costs that come with chronic care or expensive medical procedures. The result is that accessing health care as a consumer means trying to guess how much you might need without knowing how you may need it. This makes the current health insurance based system completely ineffective for dealing with catastrophic support that is supposed to be the very cornerstone of buying insurance in the first place.
Thank you for posting this story. I’d love to see it in the Globe (perhaps it already has been) or other papers. Until we make it real for everyday people, they’ll think HCR has nothing to do with their everyday lives.
My son was diagnosed Hypoplastic Left Heart syndrome, and had to stay 3 months at the hospital. In that period, he consumed his lifetime maximum. We’re still in the hospital and when we’re discharged he’ll be uninsured.
Does anyone know when does this new regulation kick-in and if it will consider existing contracts? Or will I have to go and get a quotation from a different insurer?
Thanks,
Martin