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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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  • #16
    Just a quick word. I don’t think they will drop you because of a pre-existing condition. They are slipperier then that. They will deny coverage of the pre-existing condition, but will happily continue to take your premiums for the other policy coverage’s.

    Now the situation is that you have medical coverage which excludes the pre-existing condition. Any and all time that passes just adds to the gap in coverage for that condition, and you will never get out from under unless you find an insurance company that will insure that condition also, and sufficient time elapses so that the continuous coverage clause can take effect. (Make sure you abide by every word of that clause – and have records of previously telling them all about the prior coverage. You don’t want to fight the uphill battle of first being denied and then trying to reverse that decision.)

    These babies weren’t born yesterday. Of course there is an ‘end run’ around this mess - if you are lucky enough to live in a state that has ruled against such practices. Unfortunately I can not think of any such state at this time. You can try for coverage of the condition (without the pre-existing clause) but those premiums will probably be astronomical. Remember they are in the business of collecting premiums, not paying claims.


    • #17
      Check everything very carefully. You just might have a policy that limits the exclusion for a pre-existing condition to one year or something like that. (Might be a state law involved.) If so, it will be stated in the policy. Keep reading it until you know it backward and forward – and make sure to protect yourself against any pitfalls.


      • #18

        Health insurance isn't like car insurance. THey can't drop you.


        • #19

          Dear Gary,

          Once again, BY LAW and BY THE POLICY, they can't deny coverage for a pre-existing condition more than 12 months (although some indpendant policies may have a longer term), then they have to start paying.

          Again, you have to read the policy. You are allowed to read the policy before you buy it.



          • #20
            If an insurance company "rebills" the rate that the doctors charge becase the doctor is in their network, will the insurance company still rebill this if they dont cover the condition due to a pre-exsisitng condition?

            Thank you


            • #21

              thank you.. I was under the assumption that once u have a pre exsisting condition an insurance company WILL never cover this condtion.

              So if you have a 1 yr pre exsiting condtion they dont cover it for 1 year then they cover it.

              thank you again .



              • #22
                Sarah and Gary,
                The limit to a one year exclusion is fairly universal, but I was afraid to say it, as insurance policies are controlled by state law. I don’t know which states do or do not have this proviso – I expect it’s fairly universal – but I don’t know for sure.

                As with most things of this type, state’s laws require the details to be printed in the policy. That’s why it is so very important to be sure you know what you are buying before you put your name on the dotted line. Now you not only have to drink, drink, drink, – and walk, walk, walk, - now you have to read, read, read also.

                One more thing I don’t think I can stress to strongly is that if you have no break in coverage, and are exempt from the pre-condition rule, it is very important to establish that fact with the insurance company prior to any claims being filed (they will detail how to go about this in the policy.) Once they deny a claim it’s a long hard road back to getting them to accept it. If I’m not mistaken, Mary had her claims denied under this rule. After she supplied them with the appropriate documentation they still are denying the claims, and told her she will have to sue them to get them to reverse their decision. I expect this can be resolved without having to hire an attorney, but it’s a big headache to deal with in any case.

                One more last word. You have to be careful about pre-existing conditions with health insurance companies. You do NOT have to have a prior diagnosis on file for them to deny a claim. (If you have had any prior heart problems – or just symptoms which can later be attributed to a heart problem – they can invoke that clause for just about any and all subsequent heart related claims.) As I said before, they are in the business of collecting premiums, not in the paying of claims. Their measure of success is both in the number of premiums they can collect and the number of claims they can avoid paying. (Makes you want to be rich just to avoid having to deal with insurance companies, doesn’t it?)


                • #23
                  Oops, forgot your 5:16 question.

                  Medical insurance companies go to doctors and say, “I can list you as one of our providers and bring you lots of business, but if I do that for you, I want you to give me a further discount on your charges.”

                  In fact they annually review what the doctors in an area are charging for each particular service, and set their allowable charge at something like 80% of the going rate, paying that rate to plan providers. For non-plan providers, they will go up to 110% of their allowable charge, but if the bill exceeds that limit, they go back to their basic allowable fee, and the insured then has to pay the balance. This tends to keep their insured going to in-plan doctors, and strengthens their position regarding quantity of patients supplied for a reduced fee paid. (There are wheels, within wheels, within wheels.)

                  Anyway, back to your question. If the procedure billed for is not a covered condition, the insurance company is out of the picture and the doctor can charge whatever he feels he can got for his services. There is such a thing as wishing to keep a patient however, so negotiating with the doctor over fees will often get you a reduced rate. This also holds true in regard to hospitals, where similar forces are at work. (Did you ever see a detailed hospital bill, and how much the insurance companies disallow, and how much they wind up paying?)

                  Bottom line. If the service rendered is not covered by the insurance policy, the insurance company’s agreement with the medical provider does not play any part in the picture. However, you are then free to negotiate with the provider for any reduction in fees you can get on your own.


                  • #24
                    Just a note to agree with those who say (correctly, I believe) that the laws about pre-exisiting condition coverage vary state to state and the details vary policy to policy.

                    What does your brother's insurance policy say, precisely, with regard to pre-existing conditions? (If he doesn't have a copy of his full policy to read it in, he should definitely get one from his agent/company.)

                    For instance, mine (KPS insurance, in Washington state) says: "KPS imposes a nine month waiting period before providing coverage for a Pre-existing Condition. A "Pre-existing Condition" is any condition about which, during the six month period immediately before enrolling in this Group Plan, an Enrollee received medical advice, or for which his/her Provider recommended or provided treatment.[ .... ]However, this waiting period may be reduced by the number of months of Creditable Coverage the Enrollee has accrued under other health care programs prior to their enrollment in this Group Plan. "Creditable Coverage" means periods of other health coverage an Enrollee may use to reduce pre-existing waiting periods. These include group health coverage; Medicare; Medicaid; military health coverage; Indian Health Service [etc. etc...]

                    The Enrollee will receive credit for prior Creditable Coverage if it was continuous and terminated no more than three months immediately preceding enrollment in this Group Plan Health coverage will be considered continuous if there was no more than a three month break between any Creditable Coverage [....]"

                    Get the exact wording of his policy and apply his situation:
                    First is to establish, did he have prior medical coverage that will count as continuous coverage (for mine, it would be: terminated no more than 3 months before current policy); if so, how long did he have the coverage, and how much does it lessen the waiting period for coverage of pre-existing conditions (for mine it is 9 months waiting period minus length of coverage)

                    Next: will they consider it a pre-existing condition? For my policy it is if he received a doctor's "advice" or "treatment" or "recommended treatment" within 6 months prior to start of medical insurance policy. I'm the type that would go ahead and submit the claims to them and see if they covered it or not; not red flag it by asking them ahead of time--but others have more experience with what's good to do about that.

                    If he had no prior medical coverage that counts as continuous, or a reduced waiting period, once the waiting period is over, in the case of my policy, the condition is then covered like anything else is. (They don't want us to not carry coverage, then quick sign up for it when we find we have cancer, etc.)

                    Not sure if this clarifies or not.....

                    Best of luck to him, Lisa I.


                    • #25
                      Oops, sorry. I just realized after I posted that message that this is in the "ask HCMA" section and that I'm not supposed to post in this section. I was going to delete it and post it as a personal message instead, but it says I can't. My apologies--Lisa I.


                      • #26
                        he didnt have insurance when the doctor discovered a heart murmur then doctor told him she thought she hears one and not a big deal to check it out next yr but if he was concerned he could follow up with an echo. this wa in september.. In nov he got his insurance and several months later got an echo which showed an enlarged heart slightly. When he went back to doc she mentioned to have another echo next yr but if was concerned to see a cadiologist which he did. No dx was officially mentioned yet..

                        would this be a pre existing condition. He said his policy said pre exisitng conditions would be 12 months, the doctrs advice was not to do anything but if he wanted to follow up he could.

                        so if he took took treatment after 12 months of coverage would they cover it?

                        he is asymtopmatic


                        • #27
                          To ask another question.

                          Felix is covered under aetna and my company. My company has
                          said that if a spouse can get insurance thru their own company, then
                          they have to, or I have to pay a surcharge.

                          So when felix has open enrollment, he goes ahead and enrolls. they
                          dont offer aetna at all, but cigna. So for one year, he cannot make
                          any claims against his HCM, or the insurance will not pay (if I understand
                          that correctly).

                          Now , he is still also covered under my aetna until next Jan. His new insurance would start in June. So for 6 months of it, we could make
                          claims still on aetna, correct?

                          Also, if I was to ever get laid off, and we moved all of us to felix's
                          insurance, the same thing would apply. for one year, none of hte costs
                          associated with HCM would be covered? Even if routine appt with his



                          • #28
                            It sounds to me like Felix was never without insurance coverage from one policy or the other, so it is quite possible that any pre-existing condition restrictions on his new insurance policy are not enforceable.

                            Read the policy carefully and do what it says in regard to pre-existing conditions and how to avoid having the claims denied. There is just no substitute for reading and understanding the insurance policy. All the rules and regulations concerning all parts of the policy have to be spelled out for you in the policy itself.

                            The same would apply if the family had to switch to his policy at some time in the future. We really can’t tell you what the policies say, we can only talk from our own experiences. You have to check both policy’s rules and regulations yourself.

                            Happy reading,


                            • #29
                              Hippa 1996

                              No. Felix can make HCM claims on the new policy.

                              This is KEY: IF you have had insurance for one year and change plans for any reason, you are covered. the pre-existing condition clause DOES NOT apply. (assuming that any gap between plans was 63 days or fewer)

                              You don't say which June, so I'm assuming this June, in which case Aetna would consider themselves the secondary carrier and refuse payment until the primary carrier (cigna) had paid the bills.

                              If you don't mean this June, and there is a six month gap, then you should put him on COBRA if possible and then there wouldn't be a gap.


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