Help my friend get the surgery she needs without going into massive debt!

July 29, 2009 10:12 AM

My friend needs surgery but has no insurance. She thinks she can be covered if she goes on her parent's insurance in another state and has the surgery done there. Is this true? What kind of paper trail can the insurance company find?

Health Insurancefilter: Please help me solve this insurance issue for a friend. Sorry about the length...it's complicated.

A couple months ago, my good friend 'D,' currently living in Oregon, had a cyst on her tonsils, which was removed at her own expense as she does not have health insurance (a couple hundred bucks). After leaving the hospital, she came down with a pretty bad staph infection, which is common after a minor surgery as staph tends to thrive in hospitals. Because she doesn't have insurance, she went to several free clinics to get treatment, and was given various diagnoses and antibiotics, etc.

And still, the infection persisted. After the most recent culture, she learned that the infection is MRSA, an extremely antibiotic resistant strain, and poses the risk of death. The doctor believes she needs her tonsils removed, as they may be feeding the virus, and may have to be on an intravenous antibiotic drip. But again, she has no insurance.

However, she thinks she can get on her parents insurance, who live in Florida (she is in her early twenties, and apparently there is a law in Florida that would allow her to do this?), in which case she could have the procedures done in Florida under her parents health insurance, if she claims that her permanent residence is still in Florida.

So here is the trick. She just signed a lease, along with someone else, which goes into effect August 1st. The lease is a sublet in house owned by a man who is leaving the country for the year. Its a pretty informal, personal thing, but he does have paperwork with her signature. She is wondering if the insurance company could somehow find the lease and thereby revoke her claim. Does she need to take her name off the lease? What about the fact that she's been paying Oregon state income tax? Wouldn't the insurance company find that first?

Neither of us know anything about this really, so any advice would be extremely, extremely helpful.

Thank you Hive Mind...you save lives.

posted by JaiMahodara to law & government (11 comments total)

I can't give a medical opinion, because I'm not a doctor, so I'll just say that I've had MRSA twice, both times in my nose, and both times I've wound up hospitalized, on IV antibiotics, with a face that was swollen beyond recognition.

So my only piece of totally non-medical, layman's-terms-only advice is that MRSA is nasty shit and your friend should get it taken care of quickly, no matter what she decides.
posted by xingcat at 10:38 AM on July 29

Depending on her income level and residency she may qualify for the Oregon Health Plan. In some cases you can qualify temporarily in an emergency situation even if you won't qualify after. In Minnesota state funded medical insurance can also "back bill" 3 months, like if the surgery is in July and your friend gets coverage in September it will be covered. She needs to be seen ASAP.
posted by ShadePlant at 10:43 AM on July 29

Go here to read up on eligibility for the Oregon Health Plan.

It's unlikely that the insurance company could find out she's really living in OR, but they could, and it's fraud. Her parents could lose their insurance.

Her doctor may be able to refer her to (or may have on staff, depending on the practice) a social worker who can help her figure out and apply for insurance for low-income people.

But yes, she needs to have this taken care of as quickly as possible - MRSA isn't anything to fuck around with, debt or no debt. It can kill you.
posted by rtha at 10:54 AM on July 29

FWIW, just because you have an apartment in another state doesn't mean you're not a Florida resident:

Florida Residency

(2) Any person who shall have established a domicile in the State of Florida, but who shall maintain another place or places of abode in some other state or states, may manifest and evidence his or her domicile in this state by filing in the office of the clerk of the circuit court for the county in which he or she resides, a sworn statement that his or her place of abode in Florida constitutes his or her predominant and principal home, and that he or she intends to continue it permanently as such.
posted by Comrade_robot at 11:01 AM on July 29

Could she go on charity care? Especially for an unexpected emergency like this?
posted by WeekendJen at 11:12 AM on July 29

Here's the dependent extension law. Lying on an insurance application is grounds for rescission of the policy.

(1) If an insurer offers coverage under a group, blanket, or franchise health insurance policy that insures dependent children of the policyholder or certificateholder, the policy must insure a dependent child of the policyholder or certificateholder at least until the end of the calendar year in which the child reaches the age of 25, if the child meets all of the following:

(a) The child is dependent upon the policyholder or certificateholder for support.
(b) The child is living in the household of the policyholder or certificateholder, or the child is a full-time or part-time student.

(2) A policy that is subject to the requirements of subsection (1) must also offer the policyholder or certificateholder the option to insure a child of the policyholder or certificateholder at least until the end of the calendar year in which the child reaches the age of 30, if the child:

(a) Is unmarried and does not have a dependent of his or her own;
(b) Is a resident of this state or a full-time or part-time student; and
(c) Is not provided coverage as a named subscriber, insured, enrollee, or covered person under any other group, blanket, or franchise health insurance policy or individual health benefits plan, or is not entitled to benefits under Title XVIII of the Social Security Act (Medicare).
posted by Pax at 11:17 AM on July 29

i would start looking into something other than her parents insurance, even if she does manage to get covered under them. She has a preexisting condition, clearly, and an insurance company is going to balk at covering that no matter where she lives. It will be pretty hard to convince them it is not preexisting if she goes on the insurance 7-31 and needs treatment immediately, which she does.

Usually, the coverage rules have a stipulation that you must be under a certain age and living in the household or under a certain age and a college student. If you are a college student, many times the state you go to college in doesn't matter and the age is higher than if you are not a college student.

And she needs to get treatment asap. Hospitals surely have ways to go about getting this done. It can't be that uncommon.
posted by domino at 11:18 AM on July 29

Generally there's only one set time each year when people with employer-based insurance can add or subtract family members from their policy, or switch between carriers (called the open enrollment period). There are some exceptions to this--for example, if the policyholder gets married, or divorced, or has a baby--but I'm not sure that any of them would apply to your friend. She may not be able to get onto her parents' insurance until much later in the year, depending on when that open enrollment period is, and I don't think it's wise to wait that long to treat MRSA.

I n-th the suggestion of looking into: (1) Oregon Health Plan; (2) whether any hospitals in her area offer charity care for which she may qualify (often hospitals don't advertise this so it may take some searching); or (3) whether she can convince the original doctor who scraped her tonsils to do the removal and set her up with a payment plan. I think what she has going on could fairly easily be called a complication of the original surgery, and maybe her doctor can be persuaded to fix it, even if he can't get cash up front.
posted by iminurmefi at 1:43 PM on July 29

If her parents are not claiming her as a dependent for tax purposes, it's doubtful she qualifies on their insurance anymore. I don't know if the insurance companies routinely check tax returns (they would have to request a copy of it from your friends parents, I think; the IRS wouldn't just give it to them without a Form 4506) but if the bill is big enough they might start sniffing into it, particularly if your friend went on her parents insurance and suddenly had this big claim. Just looking at it from their perspective, it's probably going to look pretty suspicious: kid goes off parents' policy, then comes back on and suddenly has a major claim — somebody looking for claims to deny is probably going to see that as a big target.

I'd be careful going down this route if I were your friend. I'm of the opinion that there's no immorality in lying to a health insurance company when somebody's life is on the line, but that's not to say that bad things can't come of it. (Like, for instance, her parents losing their policy if the fraud gets detected.)
posted by Kadin2048 at 3:03 PM on July 29

2 things: as this is playing out I got some more information. Turns out D is applying through her father's group's plan--a group of ER doctors. Under this plan preexisting conditions are NOT grounds for denial, believe it or not. Wondering how the rest of us not in The Family will get fair care.

Now that I feel better about imminent treatment the question is digging deeper: What are the OTHER risks of (still) claiming FL residency and signing an OR lease, whether accepted or denied coverage, legally speaking?

Also, nax, love you. AskMe etiquette notwithstanding, the urge to stand on soap is real and just.
posted by JaiMahodara at 7:22 PM on July 29

You can claim residency in one state and still have property, a leased apartment, a mailing address, registered vehicles, in another — it happens all the time. Generally, residency is where you have a domicile and intend to return. So someone who lives in state A but has an apartment in the city in state B would still be a legal resident of state A, even if they spend most of their workweek in state B — provided that they intend to return to state A when their work in the city is done. They might have a registered vehicle in the city, even pay taxes there, but they might not be a resident. Things can get complicated quickly, depending on how different states define 'residency.' (I've personally run into a situation where two states' standards would have both qualified me as a resident simultaneously, because they were vague; I spoke informally to a lawyer about it and was told it happens all the time and to just use whichever one I thought I'd be in permanently, but register cars and pay taxes as appropriate to stay out of trouble.)

At least IMO it's a messy area of the law. Your friend seems like she might have an argument for considering Florida her place of residence, if she kept a domicile there (with her parents) and intended to return all along, even if she just signed a lease in OR for work purposes ... but if she registers to vote in OR that might complicate things, since at least in the states I've been in, that was directly linked to residency status.

If her parents know any lawyers, particularly healthcare lawyers, it might not be bad to try to talk to one of them early on. If her claim gets questioned it could turn into a nasty paperwork hassle quickly, although it sounds like the insurance plan in question is far better than most, so maybe they won't be quite so quick to jerk her around about it.
posted by Kadin2048 at 8:08 PM on July 29