Trying to buy health insurance on your own and have gallstones? You'll automatically be denied coverage. Rheumatoid arthritis? Automatic denial. Severe acne? Probably denied. Do you take metformin, a popular drug for diabetes? Denied. Use the anti-clotting drug Plavix or Seroquel, prescribed for anti-psychotic or sleep problems? Forget about it.
This confidential information on some insurers' practices is available on the Web -- if you know where to look.
What's more, you can discover that if you lie to an insurer about your medical history and drug use, you will be rejected because data-mining companies sell information to insurers about your health, including detailed usage of prescription drugs.
These issues are moving to the forefront as the Obama administration and Congress gear up for discussions about how to reform the healthcare system so that Americans won't be rejected for insurance.
Sign Up and Save
Get six months of free digital access to the Miami Herald
It's especially timely because growing numbers are looking for individual health insurance after losing their jobs. On top of that, small businesses, which make up the bulk of South Florida's economy, are frequently finding health policies too expensive and are dropping coverage, sending even more people shopping for insurance.
The problem is, material available on the Web shows that people who have specific illnesses or use certain drugs can't buy coverage.
"This is absolutely the standard way of doing business, " said Santiago Leon, a health insurance broker in Miami. Being denied for preexisting conditions is well known, but when a person sees the usually confidential list of automatic denials for himself, "that's a eureka moment. That shows you how harsh the system is."
A 50-year-old Broward County man, with two long-standing medical conditions, saw the harshness for himself when surfing the Web trying to learn why insurers kept denying him coverage. He was shocked to find several insurers' instructions to sales personnel, usually called the Guide to Medical Underwriting and often marked "confidential and proprietary."
"I think it's atrocious what's going on, " he said. "Basically, they're taking only the healthy so they can get the fattest profits. If you really need insurance, then you can't get it."
The man, a self-employed consultant, didn't want his name or preexisting conditions identified for fear that the information might frighten away potential employers.
Insurers don't want to talk about the guides. Sunrise-based Vista, which has its 35-page "confidential and proprietary" guide tucked away within its website, refused to make executives available for an interview and instead issued a brief statement:
"The medical underwriting guidelines used by VISTA are based on industry standards, comply with all regulations and are subject to review by the Florida Department of Insurance. VISTA's Guide to Medical Underwriting is an educational tool intended to assist agents and brokers who are selling VISTA individual plans. We do not comment on our specific underwriting processes and practices."
Sandra Foertsch, who sells individual policies, says the fundamental concern of insurers is clear: "They don't want to buy a claim, " meaning that they would start to collect $500 monthly premiums from a person and quickly pay out more than that to doctors and other providers.
Foertsch said she was surprised that any of the guides could be found on the Web. "I'd guess someone made a mistake."
The Miami Herald asked several other major Florida insurers -- Aetna, Humana and Blue Cross Blue Shield of Florida -- for copies of their underwriting guides. All refused, saying they contained propriety information and were confidential.
Searching the Web, The Miami Herald found underwriting guidelines for Coventry Health Care, which owns Vista; Wellpoint; Assurant Health; and Blue Cross Blue Shield of Nebraska.
Among the health problems that the guides say should be rejected: diabetes, hepatitis C, multiple sclerosis, schizophrenia, quadriplegia, Parkinson's disease and AIDS/HIV.
Some guides echo Nebraska's warning on the Web that it's "intended as a reference tool only, " with final decisions made by managers.
Insurers have different criteria. Sleep apnea and fainting for no known cause are reasons for denial for the Nebraska plan, but not for other plans. Vista doesn't want to cover severe acne, but other guides seen don't mention it. Insurers often use measures of body mass index to reject those who are too heavy or too thin.
For cancer, the key is how patients have been doing in remission. Wellpoint, a national insurer, rejects applicants who have had breast or prostate cancer within the past five years. With other types of cancer, 10 years must have passed. Assurant Health, based in Milwaukee, rejects most patients whose cancer has not been in remission for at least eight years.
Other reasons for automatic denial by various companies: alcohol-related problems of people who have not been abstinent for at least six years, chronic bronchitis, severe migraines, and a cardiac pacemaker installed within the last two years.
Some insurers will automatically reject applicants who are using certain prescription drugs. Wellpoint denies anyone who within the past year has taken Abilify and Zyprexa for mental disorders as well as Neupogen, which is used to treat the side effects of chemotherapy. Vista lists the anticoagulant Warfarin and the pain medication Oxycontin. Both companies list insulin.
The medications, of course, are indications of specific health problems. To make sure that applicants are not lying, insurers hire a data-gathering service -- Medical Information Bureau, Milliman's Intelliscript or Ingenix Medpoint.
Intelliscript and Medpoint do computerized searches of a person's drug use, gleaned from pharmacy benefits managers and other databases. The two companies say they comply with privacy laws. "Ingenix requires each Medpoint client to obtain the authorization of the individual applicant or insured person, " said Ingenix spokeswoman Karin Olson.
Last year, the Federal Trade Commission accused both companies of violating the Fair Credit Reporting Act by not offering to provide consumers with information about them. The companies agreed to settlements in which they promised to let people see their personal information.
What do they have on you?
By law, data-mining companies are required to tell you what they're telling health insurers about you. To ask for your file, contact:
Ingenix MedPoint Compliance
Write: 2525 Lake Park Blvd., West Valley City, UT 84120
Medical Information Bureau
NOTE: Milliman and Medical Information Bureau say they will have files on you only if you have applied for individual insurance.