View Full Version : A life saving operation or treatment..

06-10-2012, 06:09 PM
for a child that an insurance company won't cover and the hospital wants payment in advance? Insurance company maybe considers the condition as pre-existing or the treatment as experimental. Better yet, the same condition passed from the now deceased mother onto the child at birth.

06-10-2012, 06:55 PM
Are you looking for conditions that this would apply for? Or whether a scenario would work like that (hospital pre-pay, etc)?

Cancer comes to mind. There are a lot of experimental treatments and trials that aren't covered by insurance, and that are extremely expensive. Sloan Kettering in NYC does a lot of these trials, but in many cases they (or whoever is sponsering the trial) will pick up the tab. Also bear in mind that when traditional insurance won't cover costs, SOMETIMES medicare/medicaid can come into play in the US. That varies from state to state and depends on family circumstances. So it's not an impossible scenario by any means, but you'd need to address why these options wouldn't come into play.

It's also possible you could pick an illness that would reach the lifetime max coverage quickly. Most insurance plans cut off around $1-2 million from what I've seen, but again--this cap varies.

06-10-2012, 07:25 PM
"Are you looking for conditions that this would apply for?"

Yes. Thanks for the medicaid mention, I've addressed why that option would come into play, and a google search led me to this:

06-10-2012, 07:33 PM
Exactly when and in which US state is your story set?

The Patient Protection and Affordable Care Act (http://en.wikipedia.org/wiki/Patient_Protection_and_Affordable_Care_Act) started going into effect in 2010. As of September 23rd, 2010, insurers cannot impose lifetime caps on essential benefits and are prohibited from excluding pre-existing conditions for children younger than 19. If your story takes place much after that, and your child character is insured, then there should be no lifetime caps nor exclusions for preexisting conditions.

Even before then, if the child was covered at birth by the insurance, then problems from birth were covered until the child changed insurance companies (subject to a lifetime cap until it was abolished in 2010). Conditions present at birth were generally not considered "pre-existing" for the purposes of exclusion by insurance companies.

Now, if the child doesn't have insurance at all, then the various State Children's Health Insurance Programs (http://en.wikipedia.org/wiki/State_Children%27s_Health_Insurance_Program) (CHIP) come into effect if the parents aren't poor enough for Medicaid (http://en.wikipedia.org/wiki/Medicaid). So which state your character lives in is important to determine what is covered.

If the condition is debilitating, then the child might also be eligible for Social Security Disability Insurance (http://en.wikipedia.org/wiki/Social_Security_Disability_Insurance) (SSDI).

It would be next to impossible for the child to not be eligible for some kind of financial help for a life threatening condition. Adults, yes. Children, no. Even if the parents were unaware of payment options, the social workers at the hospital would know all about them.

ETA: Experimental treatments are a whole 'nother ballpark and your huffpo article is correct for that, including the follow-up in the comments that an insurance company will generously pay for the procedure.

06-10-2012, 07:46 PM
Good point, Ultragoth. The changes that are happening in health care now add a whole different set of challenges for the scenario. Still not used to them after years of fighting BCBS, lol.

I'm wondering if being an undocumented resident would allow for the scenario Graz is looking for. Of course the child couldn't be born in the US or they'd be a citizen, if undocumented (easy enough to prove if it comes to saving their life, though, which I would imagine most parents would go for rather than letting them die, even if it means deportation for the parents).

06-10-2012, 07:54 PM
True, an illegal alien would not be eligible for any State or Federal health care program. In that case the child would have to be born abroad of non-citizen parents and smuggled into the United States.

Just as a general note, this demonstrates yet again how vital it is to state the precise time and place the story takes place for the most useful answers to be provided. I'm continually croggled at the number of queries on this sub forum that don't state even the century or country where the story takes place. Context on this one assumes 21st century United States but as we all know, states in the US vary so much that including the state, and even the town or city are also vital. Not a poke specifically at the OP, just a general plea to all.