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Insurance question----- pre exsisting condtion please help


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Gary Jackson Find out more about Gary Jackson
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  • Insurance question----- pre exsisting condtion please help

    After learning I had HCM I urged my other family members to get tested. My other brother who didnt have insurance at the time was diagnosed with a heart murmur last september... ( he was changing jobs and didnt have insurance) He got insurance in November. . He was told at the time he was diagnosed with a heart murmur it wasnt a big deal.
    I recommneded he go get tested for hcm. His concern was since he was dx with a heart murmur when he didnt have insurance if he has hcm now that the insurance will not cover him as it was a pre esisting condition...

    and if it not covered by his inusrance company any ideas what he can do?

    thank you


  • #2
    How long ago was he "treated" for the heart murmur? Most, policies say that within six months it would be considered a previous condition. But, if you read my earlier post with pre-existing then you know how complicated all of this can get. He needs to go over his plan with a microscope before he does anything. If his policy says six months and he feels ok enough to wait then I would. It could save him a lot of pain and heartache. no pun intended.

    Mary S.


    • #3

      there are a number of threads on the board with links and info on insurance options.

      use the search function to look for posts on insurance. also search google for "risk pool insurance" and the name of the state your bro lives in to see if his state has a plan for uninsurable people.

      there are options and no pat answer since, as Mary points, out --it depends.


      • #4
        He was dx in sept with a heart murmur. Got insurance in Nov had an echo in January saw a cardiologist in march had a holter test in march .
        no other treatement



        • #5
          if someone has a heart murmur but hasnt been diagonsed with hcm and then is diagnosed with HCM after 1 yr of a health insurance policy would HCM be a pre exsiting condition?

          thank you



          • #6
            I don't know if anyone can answer that except the insurance company.

            Most policies define it as something you've been treated for in the previous 6 to 12 months prior to coverage start date --so if the murmur was found and he was given medication for it, then yes, they could argue preexisting condition. But if there wasn't any treatment, then you are probably in the clear.

            AND most pre-existing condition clauses are only for 12 months anyway, so if he has had coverage for that long, it all becomes irrelevant. But double check the policy to make sure the terms are not longer.

            It is always a good idea to have coverage before you get tested, though, whenever possible.



            • #7

              Ya know, i've been tossing that very question around in my mind since you started the thread. I believe definitions of pre-existing condition may vary by insurance company, but here is what happened to me:

              When i had my (first) hernia operation, i happened to mention to my doctor during my initial visit with him that i had experienced sporadic groin pain in the past. It had not previously been a problem, nothing like i was currently experiencing, it just felt like i'd pulled a muscle or something. Until the time of my surgery i had never been diagnosed with a hernia. I only mentioned it in passing during the exam, and did not even give specific dates about when the previous episodes had occured.

              Bam! Pre-existing condition clause invoked... insurance paid nothing. I ended up footing the entire bill for my hernia out of my pocket, despite the fact that my insurance company had already pre-qualified me for the surgery going in!

              Turns out that after my surgery the insurance company requested additional documents from my doctor, saw in his notes that i had mentioned past groin pain, assumed that this meant i'd had the hernia prior to being covered by their policy, and used this as a convenient way to get out of paying the bill. I was never diagnosed with a hernia prior to having health insurance, in fact i'd never even seen a doctor about it.

              It's a tricky situation, and i hate to sound bitter, but if they can use a statement i made in passing to my doctor as evidence of pre-existing condition, then i'd think they could use an actual diagnosis of a heart murmur to say your HCM is a pre-existing condition.

              Just some food for thought.

              "Some days you're the dog... some days you're the hydrant."


              • #8

                I just saw what Sarah wrote (while i was busily writing my mini-novel) and she is correct about the 12-month thing. I don't believe that you can be denied now based on pre-existing condition if you have had continous coverage for 12 months. Of course, read the fine print.

                "Some days you're the dog... some days you're the hydrant."


                • #9
                  thank you for the reposnse.

                  what would be considered treatment for hcm? would an echo and stress test be considered treatement even though no exact diagnoses has been made?

                  Also once diagnosed as a pre exisiting disease does that mean the condition never gets paid on by the insurance company? Or if treatment like meds or surguery happen later on down the road would an insurance company pay it?



                  • #10

                    treatment doesn't equal testing. echos and stress tests are just tests. however, as pointed out above, insurance companies are going to fight you if they can. treatment would mean medication or surgery to correct something.

                    The 12 month rule is just that--after 12 months of coverage by the insurance company, they can't deny paying the cost of pre-existing conditions treatment or testing or whatever.

                    Please note that this is 12 months of continuous coverage with any provider (63 day max gap between company changes). As long as the gap between policies is never more than that, they can't deny coverage for pre-existing conditions any more.

                    Before 1996, it wasn't like that. I changed jobs every year after college and my pre-existing condition clause would kick in at each new job and so I was essentially not covered for three years. The Health Reform act (called HIPPA) decreed that as long as you had proof of continuous coverage, you only had to go through 1 year of the pre-existing condition clause.

                    So if you ever get a letter stating you were covered from x time to x time, that is why and it is like gold.


                    • #11

                      thank you...

                      so the pre exsisitng cause doesnt apply if you are just going for testing and not treatment? Treatement would be meds as well as suguery?

                      If someone is diagnosed with HCM and has NO treatement in 2 yrs lets say with inusrance then it doesnt become a pre existing coindtion because over 1 yr with out treatment? or once it is determined pre existing for as long as one is alive the insurance wont pay for it?

                      thank so much



                      • #12
                        Hi Gary,
                        If you don’t mind, I’d like to throw in my two cents. It might make understanding the situation easier if we discussed the various forces at work in these types of situations.

                        To begin with the insurance companies try to make their policies sound like a wonderful deal for the purchaser, so they tend to paint a rosy picture with the words they choose in the policy, while at the same time incorporating as many escape clauses as possible. This tends to make the actual coverage difficult to follow and understand.

                        As various situations arise, there is a staff of people at the insurance company who try every way they can to save the insurance company money. They therefore try every which way they can to avoid payment of as many claims as possible. An example of this is when my wife had a bracelet stolen. In the claim I referred to it as my wife’s loss. They then took the position that they do not cover losses, only theft, and refused to pay. They would usually get away with this as the cost of a lawyer to fight them would take more money then the claim is worth – which was their reason for denying the claim in the first place.

                        OK, now enough people have been burned by these outlandish practices for the various states to institute laws to try and control the more flagrant abuses attempted by the insurance companies. This then affords some protection, but the insurance companies still try to get away with everything they can. So you have to read the policy with extreme care, and make sure of every word you use in your dealings with them, and even then it is like trying to dance a ballet on a slippery ice covered slope.

                        All that said, in most states there are certain laws which govern what is and what is not a pre-existing condition. The rules are spelled out in the policy – since the actual wording of the policy has to be approved by the state which issues licenses for the various insurance companies who sell policies in your state. In most situations, if you have had a policy in force for at least a year – with no break in coverage, not even for an hour – any pre-existing condition should be covered. (Notice I said ‘most situations - - should be’.)

                        Once an insurance company has denied a claim it is easier to turn the tide with a teaspoon then to get them to reverse their decision. (It is as though their staff is rated on their effectiveness buy how many claims they deny, and how many of their denials get overturned.) It would therefore be prudent to try to avoid getting a claim denied in the first place.

                        There is usually a mechanism detailed in the policy which states how to inform the company of the length of any unbroken prior coverage by a different insurance company so that the ‘prior conditions’ will be covered. By all means supply them with the proper documentation well before any claims are filed under this provision – and make sure you have documentation proving that such documentation was supplied – and when. (Registered mail – return receipt comes to mind.)

                        I hope this is understandable. When you start talking about these policies you can’t avoid getting into the gobble-de-gook they are written and work under.


                        • #13

                          your 2 cents is alwasy apprecaited as well as anickel or a dime

                          thank you..

                          once a condition is pre exsisting even though no treatment is done does this mean that the condition is always pre--existing?



                          • #14
                            preexisting is preexisting

                            "this will go down on your permanent record." the violent femmes

                            yes, one there is a record somewhere of a diagnosis, that is it. the insurance company can get access to all your records everywhere, it seems.

                            But that doesn't mean insurance will never pay for it. It means that once you have been covered by an insurance company for a year, they will pay.

                            And to continue to have HCM covered throughout your life, you need to have continual coverage (changes in companies/policies ok with gaps less than 63 days) or a policy that doesn't have a preexisting condition clause (rare, but they exist).

                            clear as mud?


                            • #15
                              if someone is diagnosed with HCM within the first 1 year with no treatment and thus the insurance company refuses due to an pre-existing condition.

                              1) will they drop u the second yr?

                              2) if they dont drop you will they pay for any treament the second year?

                              thank u



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