Do I have diabetes for insurance purposes in the US?

June 1, 2018 11:05 AM

You are not my doctor you are not my insurance company and I’m not trying to commit fraud im trying to just save everyone a lot of trouble. I’ve had A1C over six a while. Last time it was 7. Now I’m on 1500mg of metformon no insulin. I don’t have to test my blood, but I don’t over do it on carbs, get plenty of fiber and protein etc.

So I signed up for Short Term Disability coverage through work. I’m paying out of pocket fully for the options I chose in anticipation of getting old and prone to clumsyness.

As we went through the sign up phone call, the agent rattled off a bunch of things that if I had them would mean I can’t buy insurance from them. When we hit diabetes, we had a digression about it where she said very hintingly “Did the doctor actually say you have / are diagnosed with diabetes?” And I don’t remember that phrasing, so I said no. We finished sign up. If I had said yes, she would have apologized and declined to insure me.

But when they research any claim I might make, it might turn out I’m wrong, and have to get through anticipated fmla for some damn thing with no income. I’d rather know and bump up my rainy day account instead.

So? Yes? No? Overweight my adult life, 40s, female. I’ve bought this anticipatorslly and work doesn’t do it “free” like other FMLA-qualifying employers I’ve worked for.

posted by anonymous to Health & Fitness (10 answers total)

I know someone who worked for a health insurance company and whose job it was to root through the file of people needing expensive treatment or surgery to find a reason to say they were never eligible for insurance and their insurance would be cut off when they most needed it. So basically they wouldn't investigate too hard while they took your money, but as soon as you need a pay out they'd go through with a fine-tooth comb (and probably didn't reimburse the premiums paid in the intervening years, either). I would assume that you don't have diabetes while they're taking your premiums and will have diabetes as a per-existing condition the second you start costing them any real money.
posted by If only I had a penguin... at 11:10 AM on June 1, 2018 [8 favorites]

According to the American Diabetes Association, you're diagnosed with Type 2 diabetes when your A1C is 6.5% or above. So most likely the answer is yes, though you should really check with your doctor to be sure.
posted by InfidelZombie at 11:36 AM on June 1, 2018 [4 favorites]

For what it's worth, I've had an A1C that has ranged in the low to mid 6s. My doctor told me I was pre-diabetic, but medical insurance considered me diabetic. You might want to ask this particular insurance company their exact definition of what constitutes diabetes, as it may differ from another insurance policy's definition. You'll probably save yourself alot of agita upfront if you know this info from the get go.
posted by HeyAllie at 11:37 AM on June 1, 2018 [4 favorites]

Yeah, this is sticky. They will take your money and then deny coverage. I'm a T2 with an A1C of about 5.8, on Metformin and one other pill (but no insulin), but I'm still considered as having diabetes (because I do). You really have to ask for this company's metrics for covering and denying coverage, but my gut says this is going to hurt you financially.
posted by The Wrong Kind of Cheese at 12:03 PM on June 1, 2018 [1 favorite]

As a registered nurse who takes health histories in home care settings, I have learned that clients do not always tell you everything - and that by reconciling their prescribed medications, I become much more informed about their health and health history. If anyone I assessed was taking an anti glycemic medication - which does not have to be a from of insulin, in your case it is Metformin - this is prescribed with the purpose of reducing blood sugar. Just because your A1Cs have been within range most of the time, this would be determined to be because the Metformin is keeping your blood sugar levels lower than they would have been otherwise. I would assume that you were diabetic, and be making health-education related decisions based your apparent lack of understanding of your status of diabetes. It may be that your doctor just wants to keep you within a tight range of blood sugar monitoring, but once you're on that anti glycemic, anyone looking into your health history would assume "NIDDM": non-insulin dependent diabetes.
posted by itsflyable at 1:04 PM on June 1, 2018

For at least one situation vis a vis Medicare that I'm familiar with, you are diabetic if your doctor says you are. And if not, not. Doctors did not all use the same criteria.
posted by SemiSalt at 1:34 PM on June 1, 2018

FWIW not everyone on metformin is diabetic. Its also prescribed for PCOS, even with normal blood sugar.

Does the policy have a time period where the coverage is cancelled if you're diagnosed with an exclusionary condition within x months of starting? If you've not been diagnosed with Diabetes, sounds like you may be soon. A1C over the diagnosis criteria (and increasing), even with metformin is not a good sign. You don't say how long is "a while" or how often you're getting checked.
posted by missmagenta at 1:40 PM on June 1, 2018 [1 favorite]

You are diabetic. You can ask for a copy of your last medical chart, which I'd bet has type 2 diabetes listed as an ongoing condition. You should get all of the things a diabetic gets. Diabetes can be managed with diet and exercise plus metformin. You are totally a diabetic managing your diabetes well. There is no question.
posted by Kalmya at 2:14 PM on June 1, 2018

I have had a disability insurance agent advise me to flat out lie about a preexisting condition - I'm sure she benefited from just signing people up, and then what happened to me would not be her problem. I would not trust this person at all. I think if I only had a penguin is right here.
posted by FencingGal at 2:21 PM on June 1, 2018 [1 favorite]

You could check with your doctor's biller to see what ICD 10 code they billed to your insurer. (Not sure if this would be on an EOB, but if you have them you could look). Every diagnosis has a code. If he's been billing under the code for diabetes, it would probably mean that you've got it. If you need a payout and the disability insurer checks medical records, they would doubtless encounter the code and date it was billed for. This would at least give you specific information that might be helpful regarding the date you were diagnosed with (or at least billed for) diabetes.

There are dozens of codes for multiple iterations of diabites with and without complications, and these are easy to google. Your billing code would likely be some iteration of NIDDM or pre-diabetes. You'd have to check with the disability insurer if prediabetes is exclusionary.
posted by citygirl at 2:51 PM on June 1, 2018 [1 favorite]