Health Insurance With A Pre-Existing Condition

[Legal Help]

I hope someone can help with this issue. I had recently joined a new company and was there about 2 months. I was experiencing a pain in the stomach area my doctor referred me to a surgeon who removed my gallbladder. Anthem the insurance company denied my claim due to pre-existing conditions. Prior to Anthem I had Kaiser for seven months. Before that I had 6 months with no coverage. Before that I had health insurance through work. They are using that 6 month gap to deny me coverage. I had experienced this pain off and on for years however in that last couple of years I had not attempted to treat it. I went to the doctors at Kaiser who did one ultrasound and they said there was nothing wrong. The surgeon I saw said it had to come out. The question is how it can be a pre-existing condition when I had one test in the last few years and the results were negative. And what are the chances my Gallbladder went bad during the 6 months I was not able to afford health care. I have been paying for health care for over twenty years, and the one time I need it they are screwing me. Can anyone offer any advice?

[moburkes]

What state are you in?
Is your current insurance a group or individual policy?
Was there a gap between your current coverage and Kaiser?
What EXACTLy did the denial notice say?

[Mr. Knowitall]

Welcome to the world of U.S. health insurance, in which insurance companies spend a small fortune denying claims for medical treatment. The insurer is probably using the history you gave when you were treated as a basis to deny your claim. They are using the six month lapse in coverage as a basis to deny coverage - they don't care whether or not you were insured before that time. If this is an ERISA plan, after you follow the insurer's internal appeals procedure, you would be able to sue them to enforce the contract, but you would not be able to recover compensation for your pain, suffering or aggravation, and probably not your attorney fees either, as the Supreme Court has held that ERISA preempts state "patient bill of rights" laws and despite some early false promises the Bush White House doesn't want national patients' rights legislation.

[deadlock]

I had recently joined a new company and was there about 2 months. Anthem the insurance company denied my claim due to pre-existing conditions. Prior to Anthem I had Kaiser for seven months. Before that I had 6 months with no coverage. Before that I had health insurance through work. They are using that 6 month gap to deny me coverage.

From the information above, you were without insurance for 5 months (if there was no gap between Anthem and Kaiser).

I am guessing that you received a prewritten type of denial letter stating you had a "pre-existing condition" as reason for denial. These letters are computer generated following a claims examiner's entry of a hospital bill and data in their computer base about you.

You have a 12 month period of time before your coverage will pay for treatment of a condition that had been previously treated. It is this "gap" as you said but it is because you cannot prove it didn't exist.
The carrier can waive this policy. You may need to request assistance from your employee benefit office.

Your surgeon and the hospital had to contact either your employer or carrier for verification of your coverage. You have some options but you need to get some additional information. Answer the questions moburks asked.

[moburkes]

Okay. Let me make sure that I understand. He is in OHIO.

You have had 2 months of coverage with current employer + 7 months with previous employer (during which time you had an ultrasound). Prior to that, you went 6 months with no coverage.

You will have to read your plan's policy.

However, they can exclude coverage for any condition that was treated or diagnosed in the previous 6 months.

When was your doctor's appointment at Kaiser, in relation to the doctor's appointment in which you discussed the gallbladder appt, then scheduled surgery? Were they within a 6 month time span?

[Legal Help]

The ultrasound was because I complained of a pain in that area though the test showed nothing wrong and the Doctorat Kaiser prescribed antacid, and no further tests, So how can they say it was pre-exsisting if nothing was shown. My failily doctor told me to see this surgeon who said I needed the surgery. Both the Doctor and the Hospital supposedly did a pre-screening why was this issue not raised with me.

[moburkes]

At this point, I would contact the insurance company to see if they can be more specific about your denial. It appears, though, that its valid. It could have been that the pains that you were experiencing were from your gallbladder, but the doctor just wasn't able to pinpoint it yet. Or you can try to appeal the decision. good luck

[deadlock]

A pre-existing condition is a medical condition diagnosed or treated before joining a new plan. In the past, health care given for a pre-existing condition often has not been covered for someone who joins a new plan until after a waiting period. Health Insurance Portability and Accountability Act changed the rules.

Under the law, effective July 1, 1997, a pre-existing condition will be covered without a waiting period when you join a new group plan if you have been insured the previous 12 months. This means that if you remain insured for 12 months or more, you will be able to go from one job to another, and your pre-existing condition will be covered—without additional waiting periods—even if you have a chronic illness.

If you have a pre-existing condition and have not been insured the previous 12 months before joining a new plan, the longest you will have to wait before you are covered for that condition is 12 months.

Check with either your employer benefits office or your health plan for more information and for guidelines that apply to you.

[Legal Help]

Thank you to all who replied, I think someday future generations will look back and wonder how we allowed for profit companies to decide the fate of people who need health care. Why are no politicians looking out for those of us that make up this country. It looks like I will have to hope the legal system can help.

[deadlock]

Tom,
The impact of the problem is devastating to Americans. This is just one legal resource website that is dedicated to helping persons with low income:

http://www.healthlaw.org/

Some additional information if you are interested in the subject:

http://www.hschange.com/CONTENT/689/...ugh+Trade-Offs

http://content.healthaffairs.org/cgi...tract/25/2/w89

http://www.pophealth.wisc.edu/phs548/may&cunningham.pdf

My personal opinion and advice- verify your health coverage with your employer’s employee benefit office. Statements such as “they won’t cover a preexisting illness” is not accurate and encourages one not to seek medical assistance for symptoms that may lead to serious complications if not treated.

The statement in “form letters” is misleading. You won’t be covered for preexisting conditions for the first 12 months of employment IF YOU HAVE NOT HAD HEALTH INSURANCE FOR THE PRIOR 12 MONTHS OF YOUR EMPLOYMENT.

I repeat it wasn’t the gallbladder or the surgery or the 2 months with the new company- it was the lack of insurance coverage for 12 months prior to your recent employment.

Your case was an acute episode and required immediate medical attention, in fact surgery.