Pre-Existing Conditions Can Start at Birth
Cited: ABC News
The parents of Houston Tracy, 12-year-old boy who has survived a rare birth defect, being tube and open heart surgery, found out that the term “pre-existing condition” can apply the moment a person is born. Now they are waiting to see if their battle with the insurance company will be successful.
“When he came out, he made one little cry and he didn’t really cry much,” said Houston’s father, Doug Tracy, 39, of Crowley, Texas.
Tracy cut the umbilical cord and watched the hospital staff clean his son. But before his wife Kim Tracy, 36, could touch their son doctors got worried. “We could tell there was something wrong by the way they [the doctors] were acting,” Doug Tracy said.
Houston’s skin wasn’t turning a shade of pink like most newborns because, somehow, his blood wasn’t getting enough oxygen. Doctors rushed Houston, with Tracy riding by his side, in an ambulance to Cook Children’s Medical Center in Fort Worth, Texas.
Within hours the Tracy family would learn their son was born with a heart condition called d-transposition of the great arteries, meaning the primary aorta and pulmonary arteries are transposed where they should meet the heart. Doctors wanted to operate within days to save his life.
“In Houston’s case he would not have survived had he not gotten the care,” said Dr. Steve Muyskens, pediatric cardiologist at Cook Children’s Medical Center, who treated Houston. “Most children with this [would] have demise within days to months in life.”
Muyskens explained that with the aorta and pulmonary arteries switched the system creates two separate pools of blood — a small amount that travels from the heart to the lungs and back to the heart and another pool of blood that travels from the body to the heart and back out without ever reaching the lungs for oxygen.
“The red blood just circles on one side and blue blood circles on the other,” Muyskens said. All of Houston’s organs, including his heart, would soon die without red blood.
Even if doctors could stabilize a child with Houston’s heart condition they would only have a short window to operate.
One Surgery Could Save a Life
“The Gold standard is surgery — arterial switch procedure,” said Dr. Daphne Hsu, division chief of pediatric cardiology at Montefiore Medical Center in New York. “The procedure has to be done before the child is 1 month old, because then the heart starts to change and adjust to the circulation, and the pressure in the heart drops.”
Houston was born on Monday, March 15. By Friday that week, doctors operated successfully. Muyskens expects Houston will have a normal life, and likely won’t even need medications.
“Everybody’s nicked named him Rocky around there because he’s a fighter,” said Tracy.
But by March 24, the Tracy family formally heard their son was denied health insurance.
“We don’t have health coverage on ourselves because it’s too expensive these days and because of the economy,” Doug Tracy said. The couples are small business owners and would have to buy individual policies, which they have for their other children Cooper, 4, and Jewel, 11.
Doug Tracy said the family had no idea there was something wrong with Houston before he was born.
“Prenatal, every doctor visit was perfect, his heart beat was fine,” he said. But Tracy said he called Blue Cross and Blue Shield of Texas twice in preparation of Houston’s birth, and he asked if they could get a policy on his son before he was born.
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“They said we can’t do that because he wasn’t born yet, but as soon as the baby’s born go online and fill an application out,” he said. Doug Tracy applied for Houston’s insurance March 18, and the first month’s premium of $267 was charged to his credit card, he said.
“Wednesday, the 24, is when I got a letter of decline — they declined it the day after the [health insurance] bill was signed,” Doug Tracy said.
Yet the provision in the health insurance reform act that prohibits health insurance companies from denying coverage to children with a pre-existing condition will only take effect six months after the bill was signed into law.
Family Searches for Insurance Coverage
Blue Cross and Blue Shield of Texas declined a phone interview with ABCNews.com about procedures to enroll newborns and their policies in light of the new health care reform act.
But the company was willing to e-mail a prepared statement.
“We share the public’s concern for this child and for uninsured children across our state. As you may know, federal privacy laws prohibit me from releasing any information about members or potential members of Blue Cross and Blue Shield of Texas [BCBSTX],” Margaret Jarvis, senior manager of media and public relations at Blue Cross and Blue Shield of Texas, wrote in an e-mail.
Jarvis said Blue Cross and Blue Shield of Texas would automatically cover newborns of parents who already had a policy with them for 31 days. After that time parents could opt to include their baby on their plan whether or not the child had health issues.
“For children whose parents are not BCBSTX members, who want child-only coverage, we offer individual policies, beginning at the age of 60 days,” wrote Jarvis. “BCBSTX has spoken with the father of this child, and we are exploring all available alternative coverage options.”
“I don’t hate them [Blue Cross and Blue Shield], they’ve done well for my other two kids,” Doug Tracy said. “I just want them to do the right thing.”
The Texas Health Insurance Risk Pool is an alternative family found to get their child coverage. This policy will cost $277 a month, only $10 more than the premium on the policy he tried to get for his son through Blue Cross and Blue Shield. However, he is just a little bit confused since he still has to go through Blue Cross and Blue Shield of Texas to get the new insurance coverage of Texas Health Insurance Risk Pool.
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My Take: I do not understand! How can something you were born with be considered a pre-existing condition when your insurance company starts your policy at birth. There is no way you can call it a pre-existing condition unless something is discovered during pregnancy. There is one example I can think of that occurs at birth that is not a pre-existing condition and that is a cleft palate.
Any Tallahassee FL plastic surgeon can tell you that this is not a pre-existing condition. I know that some insurance companies have tried to call this cosmetic surgery and is not covered, but it is not just cosmetic surgery it is reconstructive surgery that requires cosmetic surgery. You can talk to Pensacola plastic surgeon and keep the same answer, it is not cosmetic surgery.
It is a wonder that the insurance companies have not refused to pay for weight loss products prescribed by a doctor because obesity is a pre-existing condition. They should’ve made this new law effective immediately. Then when a doctor prescribes colon cleansers for someone who needs to lose weight, it’s not refused because it is a pre-existing condition.
I can understand them refusing to pay for something like herbal Viagra because you can buy it over the counter. In fact, safe impotence treatment, nowadays, can be done with herbal remedies and the insurance company has nothing to say about it. But get real, a burst the fact is a pre-existing condition, how ridiculous can you get?
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