To Pay or Co-Pay, That Is The Question

June 25, 2012 4:09 PM

I'm currently in therapy and unsure of whether I should use my insurance for it (thus saving money, but raising the possibility that I may be denied insurance later for a "pre-existing condition") or whether I should pay out-of-pocket (losing money, but averting the risk of a potential insurance hassle down the road).

My therapist has assured me that she will not file an insurance claim until she has made her diagnosis, and that I will be aware of the diagnosis beforehand (thus allowing me to decide whether to pay out of pocket or not). So, for what specific mental ailments would it be better to pay out-of-pocket? And for what types would it be OK to use insurance?

posted by wolfdreams01 to health & fitness (7 answers total)

Most pre-existing condition clauses entail a six month waiting period before coverage for that condition resumes. But the state of pre-existing coverage is in such flux right now that there is no way in the world to answer your question except to say do whatever you prefer. If you can afford paying cash today and don't know if you will be able to next year, I guess pay cash now. Or use insurance now and save up against a future waiting period, and then maybe you won't need it if pre-existing condition exclusions become illegal.

Unless you are diagnosed with a catastrophic neurological disorder, the likelihood of you being denied insurance entirely in the future is somewhere between "low" and "it won't be legal to deny you insurance."
posted by Lyn Never at 4:25 PM on June 25, 2012

You might want to take a look at the list of qualifying conditions for your state's high risk pool (if you have one.) My state's list includes bipolar disorder and schizophrenia - the only reason I know this is because I've been trying to figure out how I'd get health insurance for the two years between the start of SSDI and the start of Medicare coverage. Major depression isn't on the list; nor was Panic Disorder w/Agoraphobia or Schizoaffective Disorder (this surprised me.)

Also, remember that it's insurance fraud to lie on a form that asks you if you've ever (or recently) received care for [list of diagnoses] or asks for [list of diagnoses] that you have ever received care for. When filling out my health insurance's pre-existing condition paperwork, they asked in exactly that way.

I personally wouldn't fret at all about something like a mood disorder NOS. But the thing is, insurance insists on a diagnosis, and all diagnoses are at some level bad, because whatever they are, they are also most definitely pre-existing conditions. My insurance wanted to know if I'd received any treatment for a sore shoulder in the previous year.

Which is to say, being in therapy and it not being something really clear cut like "I'm here to figure out whether or not to divorce my spouse" pretty much is already relevant to the pre-existing condition issue.

(I agree that I don't think this is going to necessarily be that big of a deal in a few years' time. Insurance fraud will continue to be a VERY FREAKING HUGE deal.)
posted by Fee Phi Faux Phumb I Smell t'Socks o' a Puppetman! at 4:31 PM on June 25, 2012

Depending on your insurance options, you might want to be careful. I was denied (DENIED) healthcare coverage from UPMC because of a history of mental health problems for going to a therapist for grief counseling. This probably only applies to individual plans and won't have any bearing on group plans.
posted by Raichle at 5:16 PM on June 25, 2012

Wait until Thursday, because it's likely the Supreme Court will announce the extent to which the healthcare law will be dismantled. I would be very surprised if the part that bans exclusion on the basis of pre-existing conditions will be struck down, but you never know. However, if that part of the law is kept but the mandate is struck down, it will be legal for the time being to charge such a high premium that you are effectively priced out of the market. If the law remains intact, you have pretty much no reason not to use your insurance. No one can be totally sure what the state of health care will be in five years, but I'm with the others who think that there is good reason to believe that denials like Raichle experienced will no longer be legal.
posted by slow graffiti at 5:22 PM on June 25, 2012

Keep in mind though that you can sometimes void an insurance policy by failing to disclose relevant pre-existing conditions. So, even if you opt to pay privately, you may run the risk of having no coverage when you need it, if you breach a material term of any later insurance contract you enter.
posted by Pomo at 5:28 PM on June 25, 2012 [4 favorites]

Kind of like Raichle, my friend was denied health care based on having gotten "psychotherapy." They didn't mention his diagnosis, just the fact that his previous insurance had paid for him to go to therapy.
posted by feets at 4:54 AM on June 26, 2012

i too have had issues with individual health insurance that i did not get thru an employer or school where i was a student, from either a 6 month waiting to not covering that specific condition at all. group health i've not had a problem with.
posted by sio42 at 6:34 AM on June 26, 2012