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

[Gary Jackson]

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

Gary

[Toogoofy317]

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.

[Sarah]

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.

[Gary Jackson]

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

Gary

[Gary Jackson]

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

Gary

[Sarah]

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.

S

[mtlieb]

Gary,

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.

Jim

[mtlieb]

Gary,

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. ;)

Jim

[Gary Jackson]

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?

thanx

[Sarah]

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.

[Gary Jackson]

Sarah

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

Gary

[Burton Borrok]

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.
Burt

[Gary Jackson]

Burt

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?

Gary

[Sarah]

"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?
:)

[Gary Jackson]

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

Gary

[Burton Borrok]

Garry,
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.
Burt

[Burton Borrok]

PS
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.
Burt

[Sarah]

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

[Sarah]

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.

S

[Gary Jackson]

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

[Gary Jackson]

Sarah

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 .

Gary

[Burton Borrok]

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?)
Burt

[Burton Borrok]

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.
Burt

[Lisa Inman]

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.

[Lisa Inman]

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.

[Gary Jackson]

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

[sandylevitt]

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
cardiologist?

confused.
sandy

[Burton Borrok]

Sandy,
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,
Burt

[Sarah]

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.