A Tumor Grows in the Health System's Gaps

When doctors found a tumor in Tim Blacke's brain, health insurance was the last thing he worried about. That was his first mistake.

For nearly two decades, he'd worked for internationally known evangelical minister Josh McDowell. During that time, Mr. Blacke and his family were covered by group health insurance. In January 2007, he left to start a nonprofit ministry of his own. He paid for COBRA coverage for a while and then went uninsured for a few months. In September 2007, Mr. Blacke bought health insurance for himself, his wife and three sons. He was 38 years old.

A month later, concerned that he had developed hearing loss, Mr. Blacke consulted a doctor for what he thought was a build-up of ear wax. The doctor said ear wax wasn't the problem and suggested further tests.

Anthem Blue Cross Blue Shield, the company that sold him his insurance policy, authorized the tests. The tests revealed that Mr. Blacke had a tumor. Anthem authorized visits to a cancer specialist in Kansas City, 250 miles from his home in Branson.

It also authorized his trip to Johns Hopkins University Hospital in Baltimore, where doctors performed a painstaking, six-hour surgery to disentangle the tumor from nerves that control his hearing and balance and the muscles in his face.

The insurance company approved all that care. But then it refused to pay the $106,000 in charges. Anthem Blue Cross ruled that Mr. Blacke's tumor was a pre-existing condition. Reason: He had failed to disclose his hearing loss when he bought his health insurance policy.

Mr. Blacke's problems are shared by many of the 26.7 million Americans who buy health insurance on their own. No one knows for certain how often people like him have their insurance retroactively cancelled or their coverage curtailed.

But testimony at a congressional hearing in June shows that three large health insurance companies did just that at least 20,000 times between 2003 and 2007. It saved them $300 million in claims expenses. Insurers say they do it to control fraud, which, by some estimates, costs an estimated $100 billion every year.

They point out that financially it would be ruinous to let people wait until they get seriously ill before buying insurance, especially at the price offered to a person assumed to be healthy.

But there is evidence that at least some companies have been very aggressive in canceling or curtailing policies after claims are filed.

Insurers have developed extensive lists of diagnostic codes that, when used in medical claims, trigger intensive scrutiny. WellPoint, which owns Anthem Blue Cross Blue Shield, has 1,400 codes on its list. Assurant Health has more than 2,000.

Anthem and WellPoint are among five large insurance companies that have been fined a total of almost $19 million by California regulators over the past 18 months for improperly dropping coverage after costumers got sick.

In Missouri, people who buy health insurance are required to disclose any illness or injury that previously was diagnosed or treated.

They also must disclose symptoms that would cause an "ordinary, prudent person" to seek medical care.

It seems like a pretty clear standard, but it's not. That's what caused Mr. Blacke's problem.

His insurance company said he failed to mention he had hearing loss in his left ear when he applied for his policy. In fact, he also had hearing loss in his right ear.

"Hearing loss is a relatively common symptom which is rarely caused by tumors," his surgeon, Dr. Lloyd B. Minor, later wrote. That's especially true when patients have hearing loss in both ears.

Mr. Blacke said that no one asked about hearing loss when he bought the policy. Since his insurance didn't cover hearing aids, he never thought to mention it.

You might think he should have been more careful when he filled out the insurance application. But he didn't fill out the application. He had contacted an agent by phone. The agent handled his paperwork.

Later, after bills for his doctor visits and surgery had been sent to collection agencies, Mr. Blacke filed two appeals with Anthem Blue Cross. He was required to file that paperwork himself. He had no attorney and wasn't permitted to speak directly with anyone reviewing the case.

The final denial was dated April 14. "We regret to inform you that we must uphold our pre-existing denial decision, as our research shows that your claims were processed correctly," the company wrote.

Mr. Blacke sold his truck and some home furnishings. He liquidated the retirement accounts he'd set up for his wife and himself. After negotiating with his doctors and the hospital, he paid $57,000 to settle his $106,000 bill.

This spring, just a few weeks after he filed suit against Anthem Blue Cross Blue Shield in St. Louis Circuit Court, the company relented. It paid the doctors and hospital.

A spokeswoman for Anthem Blue Cross Blue Shield said it hadn't realized the treatments had been pre-authorized when the appeals were denied. Even though the company still claims Mr. Blacke had a pre-existing condition, it decided it should pay because it had pre-approved the care.

Mr. Blacke has yet to be reimbursed for his $57,000; it's not clear if, or when, he will. The company's cost to settle the case was far less than that. Unlike Mr. Blacke, it has market clout to negotiate lower rates.

In the meantime, his credit rating is ruined, he is facing tax bills for cashing out retirement investments, and his truck and furnishings are gone.

"I grew up in poverty," Mr. Blacke said last week. "My parents, to this day, have never had health insurance. I just always had an attitude that you pull yourself up by your bootstraps."

This experience has changed that. "The whole system is totally broke, but I never realized it before," he said.

Health care reform bills pending in Congress would end coverage exclusions for pre-existing conditions. But reform won't come soon enough for Tim Blacke, his wife, Tammy, or their three children.

On Friday, Mr. Blacke had a routine brain scan that revealed new signs of

trouble. The tumor has returned.

REPRINTED FROM THE ST. LOUIS POST-DISPATCH.

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