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  1. #1
    Join Date
    Mar 2011
    Posts
    4

    Default Possible Denial of Insurance Coverage Due to a Pre-Existing Condition

    My question involves insurance law for the state of: Florida.. I recently received a large hospital bill, my insurance company has not paid it because they are investigating if it is a 'pre existing' condition. I have a group PPO plan and I have been on the plan for around 9 months. I have never received treatment for this injury in the past, but I did not have coverage for 2008-2009. Can they deny my claim as pre-existing? is there anything I can do to insure the investigation come out favorably?? if they do deny me, what recourse do I have??

  2. #2
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,390

    Default Re: Pre Existing Condition - Florida

    If you have never received treatment for it in the past, then it cannot be pre-existing. Did you have coverage in 2009-2010 prior to coming onto this plan? If so, for how long?

  3. #3

    Default Re: Pre Existing Condition - Florida

    Untreated doesn't mean it didn't exist before, and you admit that it did.

    Most likely, the insurance company is trying to find out if they can pass the bill on to someone else, such as your employer. Usually they send a letter to that effect and ask you to confirm that no one else is responsible for it.

  4. #4
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,390

    Default Re: Pre Existing Condition - Florida

    Mittens, for the record, I work with health insurance benefits for living and know quite well what the rules are for pre-existing conditions. It doesn't matter a damn whether the condition existed before - the ONLY thing that matters is whether it was treated, and if so, when. It also matters how long before the new policy went into effect, was the insured covered or not covered by other insurance. That is Federal law, as long as it is a group policy. So sit down and let the grown ups talk, okay?

  5. #5
    Join Date
    Mar 2011
    Posts
    4

    Default Re: Pre Existing Condition - Florida

    Thank you both for the quick response.. a little more info, I was not covered in 2009. But again, I also was not treated. The first time i visited the doctor (the dr. my insurer recommended) was in November 2010, nearly 5 months after my coverage began. I spoke with the insurance company and they mentioned they are waiting to receive my doctors notes. What can they determine after viewing the notes?? and is there any validity to passing the buck to my employer and not myself?? thanks in advance.

  6. #6
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,390

    Default Re: Pre Existing Condition - Florida

    Okay, I need exact dates here.

    On what date did your coverage with the current policy begin?

    At that time, how long had you been without coverage?

    Had you ever - EVER - been treated for this condition previous to November 2010, and if so, when?

    What is the date of service for the bill that is being investigated?

    If you can answer these questions for me, we can go from there.

  7. #7
    Join Date
    Mar 2011
    Posts
    4

    Default Re: Pre Existing Condition - Florida

    thanks cbg.. My coverage began July 2010.
    2007 I was insured by this same insurer, but 2008-June 2010 I was without coverage.
    No, I have Never Ever been treated for this before..
    I first visited the Dr. November 2010.
    The biopsy bill in question is dated 1/20/2011.

  8. #8
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,390

    Default Re: Pre Existing Condition - Florida

    Then you can relax.

    The look back period for coverage that begins in July 2010, would be January 2010-June 2010. As long as you did not have any treatment for this condition during that time period, the ultimate decision will be that it was not pre-existing. This is very much routine; nothing unusual is happening. When there has been a gap in coverage, they have not only the right but the responsibility to conduct this kind of investigation. All they are going to be looking for in the doctor's notes is whether or not there was any treatment during the look back period. When they find that there was not, the bill will be processed for payment.

    Please ignore mitten's comment about "passing the buck to your employer" - there is no validity to that whatsoever.

  9. #9
    Join Date
    Mar 2011
    Posts
    4

    Default Re: Pre Existing Condition - Florida

    what a relief, thanks for all your great insight

  10. #10
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,390

    Default Re: Pre Existing Condition - Florida

    You're quite welcome. This can be hard to interpret if you don't deal with it regularly, but as I indicated, this is what I do for a living. Glad I was able to help!

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