Insurance Policy
I don’t think I am understanding my policy
correctly. Or else they are making it difficult to. Okay, my
lapse of insurance is more than 63 days. Now, even
though I have never requested this surgery before, and
there are other medical reasons for having the surgery
(possiible double knee surgery, urine incontinence, weak
ankles (whereby I fall quite often), depression, etc.),
is it still considered pre-existing?? Or does this
apply to any surgery that there is an existing waiting
period of one year? I have BC/BS PPO. Does anyone else
have this and can they possible clarify this?
May 18th, 2004 at 5:18 am
Due to the lapse in coverage of over 63 days -
your prior coverage will probably not be considered.
<br><br>More than likely when your insurance company receives
your first claim they will start a pre-existing
investigation on you. You need to check your policy language to
see what your pre-existing limitations are. Usually,
if you are treated for a diagnosis prior to and
after your effective date this would be considered
pre-existing (this is only one example). Per the federal law a
diagnosis cannot be considered as pre-existing after 12
months of coverage (18 months if you were a late
enrollee).<br><br>As BC/BS writes hundreds of different policies you
need to check your policy language to see what applies
to your situation.<br><br>The big question will
be…..Have you been treated for this condition prior to your
effective date???
May 18th, 2004 at 3:12 pm
Anser to your question…Yes. With Phen-phen in
1997, phen alone in June 2000 and then xenical in July
2000. The way I understand it is that if there is a
lapse, then they can only go back 6 months to see if
this is pre-existing. My boss is a lawyer and she
overheard me talking to BC/BS on the phone and wondered if
she could help. She gave me the ERISA / HIPAA
handbook. According to the law, they can only go back into
your medical records 6 months to consider this
pre-existing. Yes, I have always been overweight. But with the
lapse in coverage (which appears to be to my benefits
at this moment) and not seeing my doctor since
August 14 — and..my new enrollment was March 18, 2001
with coverage starting April 1, 2001, it appears that
they cannot hold this against me. You seem to know
what you are talking about so do I need to get a
letter from my previous doctor stating only when I saw
her last??? Or does she need to tell them that it was
for my weight? Or my new doctor here has ordered a
copy of my medical records…..can he write that
letter? I was hoping that I don’t need to wait for them
to come to me. Is there anyway I can help along this
process. My surgery date is set for June 14th! Thanks for
all your knowledge. It is really helpful.
May 20th, 2004 at 4:07 pm
The more information you give your insurance
company they better off you will be in the long run. For
some reason I have found many…..many physician
office do not respond back to the insurance company when
they have requested additional information. Several of
the office personnel I have spoken with have advised
me they didn’t know why the information was
requested. Believe you me, if the insurance company didn’t
need the information they sure wouldn’t waste their
time requesting it.<br><br>Be sure to check your
policy language if it states pec is only three months
then that is what would apply. HIPAA is a standard
guideline which helps people whose pec exceeds the HIPAA
guideline as this is a federal law, HIPAA will apply to
those insureds. You should always receive the better
benefit.<br><br>It cost the company I work for $7.00 for each letter
we send out. Therefore, nothing is to be requested
if it is not necessary.<br><br>Sincerely,<br><br>Ms.
Suzee Homemaker<br>Medical Claims Analyst<br>Major
Insurance Company
May 21st, 2004 at 12:42 pm
Hi Suzee,<br>I know you work for a major
insurance company, and your expertise is probably much more
than mine. But I must disagree with you when you say
the insurance company will not request information
unless they really need it. In my experience, the
insurance company routinely requests additional information
on all claims just to STALL. For instance, my son,
who is three years old fell down and got a big gash
on his nose. The insurance company sent us a request
for additional information asking us to verify that
the accident was not work-related. He is only three
years old!!! But, we filled out the form and sent it
back. Another six weeks later, they sent us the exact
same request again. I believe they are wasting their
time and my time in hopes that I will just give up and
pay the bills out of my own pocket. I have seen this
type of behavior repeatedly from multiple different
insurance companies over the years. It is very frustrating,
and I can’t believe it is completely an accident on
the insurance company’s part. I don’t mean to insult
you in any way, I am just saying that my experience
is very different from what you are claiming. –
Lynn