Preexisting Conditions?

[Lukkychrm42]

My insurance, over the past 7 months and 28 days, has not paid a single doctor's bill. It pays about $700 a month in medicine, but every bill from the doctors, it charges us for, either to fill my huge deductible or lists as a preexisting condition. The only conditions that I was being treated for as of January 2006 when the new insurance "kicked in" (in theory), were GERD and POTS. Everything else was treated as a one-off and managed with over-the-counter drugs.

I have in my hand a bill for $3000 with each of 5 charges being denied as a preexisting condition. The new doctors I'm seeing include: the geneticist, GI doc, and a PCP for back pain. It was never noted by any doctor before 2006 that I had sx of EDS, or GI issues (this includes the bill for the colonoscopy), or arthritis/degen. disc disease. The clause states: "Pre-existing condition" means a condition which manifests itself in such a manner as would cause an ordinarily prudent person to seek medical advice, diagnosis, care or treatment within 12 months immediately preceding his or her Effective Date. As I never had CAUSE to see these doctors before, and certainly had no dx, treatment, or advice based on those issues, can they legally define everything as a preexisting condition?

I have an appeal in the mail, but you know insurance companies. Have any of you fought and won on a small scale? I've tried before and lost $$$.

The thing that's bull$#%^ is that they forced me to be on my own policy with a high deductible AND premium because I have preexisting conditions. My mom did, too, and they covered her. But like I said, they haven't paid any of my doctors a cent yet. Even though we've been paying deductible and premium. My POTS dr. isn't covered, because that was actually a PEC, and when the insurance wouldn't pay him, he cut our bill into about 1/4 for us to pay.

OK I'm sorry this is so much detail and all, but do I have any legal recourse over the situation? We're already just about to drop them totally to go for my school insurance which had no PEC clause and pays only $2000 of meds per year...

Thanks, and sorry this is so long-winded! If you can't tell, I just had a long and frustrating phone call with them!

[Dawg Tired]

Okay.... Now, do I understand that your insurance is with the same employer all along?

And - have they switched TYPES of insurance - now, I'm not talking about insurance companies - actual insurance... as in, did they go from an indemnity policy to a Third-Party Administrator? (TPA)??

Also, look at your policy - see what coverage is.

The bills that have been not covered - file an appeal.... first they have to go back over it themselves, if they still deny it - file the second appeal - then it has to go higher.... the third appeal it actually has to be reviewed by an independant board to decide if they should cover it or not.

Like everything else we go through...... appeal, appeal, appeal!

[Lukkychrm42]

No- my dad went from working as part of a group to being self-employed, and we had 18 months to get new insurance, and we went from a CIGNA HMO to Anthem BCBS PPO.

According to my policy, outpatient diagnostic procedures are covered where the physician ordering them diagnoses or suspects the condition. I believe this to be the category under which these particular claims fall. And they were, and they did.

Thanks, though, I definitely will go for these appeals.

Sigh.

[Sunfish]

sorry to hear you're in such a cruddy situation with your insurance.

i definitely agree that you should appeal, appeal, appeal. and if they give the option to do so over the phone or in writing, take the "in writing" option. much better to have things documented.

one potential issue you "could" run into though, if they actually know anything about what they are talking about medically (which i would not at all assume to be the case), is that a POTS diagnosis could be stretched to encompass so many signs/symptoms, i.e. GI, fatigue, dizziness, hypermobility, etc. i'm not saying they're in the right here, only that most people who do understand dysautonomias would attest to possible relationships between many if not all of these things. i don't see how they could argue for the the back pain/ degenerative disk stuff being pre-existing though unless you've had falls related to POTS.

hang in there & good luck...i know first hand how stressful & draining insurance fights can be,

melissa

p.s. another issue to explore may be to find out HOW your doctor is indicating the need for referrals. if there is ANY mention of POTS/dysautonomia being related to why you need certain testing/referrals, that could be BCBS's way out of paying. probably not something that could be changed going back bt good to be aware of going forward...

[Dawg Tired]

Okay... here is what you need to do - when your dad went from being self-employed to the BCBS PPO, Cigna had to issue a "Certificate of Insurability" for each of you covered under the policy - Sometimes they are issued at the time you take up COBRA coverage and sometimes they are issued after it is dropped - but - under ERISA, they have to issue them. So, the next insurance company - because of the COI, cannot claim a pre-existing condition..... But they will TRY!!

In my past life I was an insurance nurse!

[Sunfish]

i know about the COIs, but have a quick question (just out of curiousity).

do they have to be presented to the new company within a certain time period?

and aren't there exceptions to their use? i.e. i'm insured now under my former employer (part of PTD plan) but will lose the insurance next june. i'm quite certain there's no way for me to get insurance after that which is why i desparately need my SSDI/medicare to come through. sorry to hijack the thread, but am i missing something??

melissa

[deeplyset]

Ooohhh, I so feel you with the pre-exsisting stuff!!! I have soooo been there. I just went though this with my insurance company (great west - if famous for this stuff).

HANG IN THERE... I don't know if your policy has a preclaimer like this or not but mine did. It said that anything that was a preexisting condition will only not be covered for the first year you have the insurance!

So if you are 7 months into it you may only have 3 months to go. I would look into it and see if they have any time frames like that on there.

Also, did you have prior insurance coverage prior to getting this insurance? Sometimes they can only deny payment if you were not being consistently covered by anothing insurance prior to this coverage beginning. I would call and talk to your state insurance regulartory agency about the rule and they can give you guidance on how to fight it without having to hire the lawyer and spend all the money. The insurance regulary agency job is to give you advice and keep them inline.

Another thing I learned is that the insurance companies are only going to be paying things according to what the diagnositic codes your doctors are submitting. I know that may be benifical information when dealing with the preexisting condition. Because if your doctor submitting a certain bill with a certain code the insurance company will tag it accordingly (even it it wasn't exactly what you had gone to the doctor for).

From my experience I found that gathering all my EOB - or explanations of benefits and learning how to read them (by spending hours on the phone talking to the insurance company asking questions as well as my providers) has helped put some power back in my hand in getting my bills paid.

I use to just take those and threw them aside (not really understanding them) but when all this pre-existing crap starting happen I starting to learn how to read those and found out how vital they are. EOB are what the insurance company sends the provider to tell them how they get paid. If you take time to make sure they line up with your policy and which bills they are and aren't paying and HOW much it will help clarify and unconfuse so much. THE EOB will do that.

The other tool that will help is itemize statements from your providers. You can call your providers and request an itemize statement. It will tell you who's paid what, who hasn't and why. It's basically a print out of your account (that you are entiled too). it will help you figure out exactly what the insurance company is and isn't doing.

But overall the best thing I ever did and still do dealing with this is CALL THE INSURANCE COMPANY customer service agents. They can work so much on your behalf. They can file claim, fix problem, reprocess unpaid claims, and fix alot of this pre-exisiting junk without even having to do the appeals (although never don't file them). They can explain policy by you just asking question after question and the more you know the systems the less you get pushed around and taken by them.

As far as the outstanding bills, contact your providers and ask them if you can have a hardship application (for people if a finical difficult situation). I got over $150,000 in medical bill written off through hardship application while going through this with my insurance company. You'll be surprise at how willing people are to work with you if your willing to work with them.

Most of all HANG IN THERE. I know it's so stressful and i know the last thing we need is stress.

[Dawg Tired]

The COI's are issued to the employee - not to the new insurance company! They usually arrive kind of hidden among a lot of other paperwork and it usually isn't obvious what it is.... It is up to you to present them to your new insurance company and your time to do that is limited - not sure now just what it is.

Unfortunately, insurance that is not part of a group policy can deny certain things. Considering the age of both of you - it may behoove you to check into your state's Medicaid system. I know you might have to somehow present yourself as not living with parents.

Also - insurance considerations are the #1 reason we shouls all file as early as possible for SSDI and keep up with the appeals - Trying to get coverage is almost impossible!

[Sunfish]

yep, i know the COI originally presented to the employee...regarding the timing i was referring to if the employee had to issue it to the new company within a certain time period. sorry for the confusion.

and that's what i thought about private vs. group insurance.....which if the BCBS megan now has isn't a group policy, i wasn't sure if a COI would help....

for me medicaid would be complicated as my LTD money puts me just over the income limits. there may be spend-down options but by the time i "may" be uninsured i'll be living with my parents and i can't just lie about that. i've been looking into everything obcessively as being uninsured could literally be a life & death matter for me now that i'm dependant on TPN. it's a pretty scary proposition & one i'm hoping & praying won't come to pass. i applied for SSDI over a year ago and you're right that it's the insurance i really need. if it comes through in time i'll have medicare before my other insurance runs out; the alternative is really too overwhelming to even comprehend.

i REALLY hope you are able to win against the big guys megan. i actually have BCBS PPO too but mine is through a group plan with one of the largest corporations in the country so obviously it's different.

hang in there & good luck,

melissa

[Cheryl]

One other suggestion. When I get statements from the insurance company, they list the medical charge, and then they charge allowed. Usually about half the bill goes poof. If they haven't adjusted the charges, try asking the doctors for the lower billing.

Insurance companies waste more time and money with this nonsense.

[Beccapooh]

In my former life, I was an insurance agent and underwriter. Here in Colorado, it is ILLEGAL for an insurance company to "claim" pre-existing condition as long as you were contiously insured. Even that was with COBRA or with a group and then you switched to individual, it doesn't matter. As long as there wasn't a gap in coverage, you're fine......here in Colorado.

Not being licensed in any other states, I can't be certain, but it would seem to me that that would be consistent across the states, no?

Did you have a gap in coverage? I agree, with needing to show them a COI, however, again, here, there is no time "limit" or guideline that states you have to show it to your new insurance company by any set date. Of course, the hope is that, once things start coming up "unpaid", you'll have the drive and need to get them that COI quickly. I'm not sure, but you if you can't find your COI, you might be able to request a copy of it from the insurance company that you were with prior to all this mess!!

Good luck and I'm so sorry. I do know how you feel. Mine isn't considered a pre-existing, but we have a huge deductible and out of pocket max that NOTHING seems to apply to!!!

Geez..............

Bec

[Lukkychrm42]

Phew! Thanks so much, everyone, for your expertise and experience! There's definitely a lot here to go over, and talk to the parents about. I think part of the problem is that they don't really care- they just pay. And I'm not going to be able to do that in the future!! My Dad said he had to give the COI to BCBS- and that was that...

There was no lapse in coverage, and I thought that prevented a claim of pre-existing condition, and I guess I don't really think that my parents spent all that much time looking over their/ my options.

Which is probably why I'm switching to the policy offered through school- there's no PEC clause, and they led me to the specialist in CO Springs. It doesn't cover much medicine, but it still seems less out-of-pocket overall.

Right now, I am living at home before going back to school, but my permanent address is still here in VA. Also, I haven't worked since last summer, so my parents can claim me as a dependent this year. But- I'm planning to work in the future- as a literary translator, which means I could work from home, and so I'm not sure about the whole SSDI thing. Plus, I'm planning to live in the E.U. (UK/ Italy) during my working life, so I'll have at least basic healthcare covered.

Deeplyset- apart from the other advice and helpfulness, you must have one nice insurance company, because the CS people I always talk to are haughty, unhelpful, and sound annoyed that I should have deigned to question anything. Haha. I won't give up, though!

Anyway, I'll keep looking into it all and become best buddies with my policy info!! THANK YOU!!

[Dawg Tired]

So, were you ever on the BCBS??? If so, they should have given you another COI - to give to whoever you have now.

[Lukkychrm42]

Oh yeah- I'm on BCBS now and have been since January. I'm switching to the school insurance next month. Thanks!

[deeplyset]

Deeplyset- apart from the other advice and helpfulness, you must have one nice insurance company, because the CS people I always talk to are haughty, unhelpful, and sound annoyed that I should have deigned to question anything. Haha. I won't give up, though!

Oh I hear you!

I get a lot of the haughty, unhelpful and annoyed people. I just point out to them I'm trying to understand what is going on and they are being haughty, unhelpful and sound annoyed and if they have a problem assisting me as a costumer service respresentative then I would glad speak to their supervisor.

That usually straightens them up. Rather than me getting frustrated and dealing with the crap they deal out and just point it out and move on to some one else even if it means hang up and calling right back to get someone else in the office. Or simiply asking to speak to someone else a little more patient and nicer. It works. I play the card "well obvious you can't explain this to me to send me to someone who can." Their job is to service you (no matter your need and how dunce you may sound) so push till you get it serviced.

You have to be persisent to make them do there job. Nobody wants to work harder than they have too. After all they just get paid the same whether they sit there or talk to you. Make them earn there money.

Good luck and again be patient with yourself and hang in there IT'S SOO SOO Hard. If you want to email me directly with more questions it's angel_2me30@hotmail.com

One thing about SSD that I didn't know until it just happened is that once you are on SSD for 2 years your automatically become eligibile and they enrol you in Medicare (you then get state funded medical insurance) so as long as you can hold out and get insurance coverage until then (for two years) you will be good to go.

Another reason to get SSD as soon as possible.

And under COBRA they have to let you have extentions on your COBRA until you get Medicare coverage. Because there are qualifiy events (with SSD) to extend it until that time.

So, the benefits of that it the if you have continuing coverage it cancels out pre-existing conditions (in most states - I would talk to my state insurance regulartory agent for help on this)

HANG IN THERE EVERYBODY

[MightyMouse]

Okay, I thought I'd share something that might be useful on this topic--

in the state of NJ, there are NO pre-existing condition exemptions. Even if you change insurers, have a lapse, whatever... EVERYTHING is covered. This works if you're living in another state and working in NJ, or living in NJ and working in another state. It's part of the reason that Teri and I have yet to go back to living on the PA side of the Delaware River, despite the lower taxes and more reasonable cost of living.

So, all my medications, doctor's visits and tests are covered fully so long as I'm in-network and follow whatever pre-approval process is in place. It's not always easy to get certain tests covered, but so far, I've been able to get everything I needed or was request by my doctors in a reasonable period of time.

Some may recall that I did have horrible bills from my spinal surgery--and that is because I had to go out of network b/c no one here would do the surgery to repair my broken neck as I was considered to be another doctor's liability (meaning potential lawsuit over the failed first neck surgery). What stinks is that the first surgery with the very same doctor was IN NETWORK, but the hospital he worked at was purchased by another group and changed systems. 8 months later it's not in-network = more $$ than you want to know about in bills (more than 50,000 $ usd total). The hospital refused to discount their bill despite the fact that I didn't work for more than a year and made less than 5,000 in disability pay. The surgeon dropped his entire bill, but the neuro, radiolgists, anesthesia, respriratory therapists, etc., all charged full amounts. That was 4 years ago and I'm still paying...

Back to topic--sorry, I comiserate completely with where you're at financially b/c of all this-- just wanted to say NJ is good for something!

Nina

[Sunfish]

And under COBRA they have to let you have extentions on your COBRA until you get Medicare coverage. Because there are qualifiy events (with SSD) to extend it until that time.

please correct me if i'm wrong, but my understanding (after a LOT of reading/research) is that this is only the case if you have already been approved for SSDI. thus, it does no good if you're in the "waiting to get approved" stage of the game. (i live in the fourth worst county in the country in terms of wait-time which means it could be almost 4 YEARS from my initial application until i get coverage.) and i did apply early in the game....about 6 months after i had to stop working.

melissa

[Dawg Tired]

I sympathize..... I applied the Monday after hubby had to come to work to get me because I could not sit up anymore.... that was sept 12, 2002..... I got my first check January 2005!

[deeplyset]

And under COBRA they have to let you have extentions on your COBRA until you get Medicare coverage. Because there are qualifiy events (with SSD) to extend it until that time.

please correct me if i'm wrong, but my understanding (after a LOT of reading/research) is that this is only the case if you have already been approved for SSDI. thus, it does no good if you're in the "waiting to get approved" stage of the game. (i live in the fourth worst county in the country in terms of wait-time which means it could be almost 4 YEARS from my initial application until i get coverage.) and i did apply early in the game....about 6 months after i had to stop working.

melissa

Melissa,

From my experience with COBRA you can normally have 18 months of coverage but if you are determined Disabled through the Federal Government it is considered a qualifying event and COBRA can be extened 29 months (if you notify your employer within I think like 30 days). Then Eligibility for Medicare is another qualifiying event where coverage can be extended to like 36 months. I know that the purpose of COBRA (CONSOLIDATED OMNIMUS BUDGET RECONCILIATION ACT OF 1985) was to get people to have medical coverage until the point of Medicare taking over (2 years) so most empolyers with end the coverage once Medicare kicks in or until they get another insurance coverage.

I'm not an expert and most of my questions I have had been answered by talking to the administratiors and regulators of COBRA in San Franisco - you can get in contact with them through the department of labor - 1-866-444-3272 ext. 2 or read online at www.dol.gov/ebsa. But I suggest talking to live people it's so much easier plus they will fight for you and on your behalf.

I know this (extention of COBRA) is very regulated. If you want to get extented coverage you have to play the game by their rules. Which is frustrating and hard (because it's not like it's one cheap or two they make it uncomplication or easy or even inform us on what exactly to do).

I know I had to apply for SSD within certain amount of time my COBRA began. I would suggest calling that number to ask the specfics. I don't remember. But I do believe that once you put in the application no matter how long it takes them to process it that becomes your officical Application date. Then depending on when the get it done that make an Entitlement date and back pay unually 6 months. For example:

I became disable on Jan. 2004 - I went on COBRA on June of 2004 I applied for SSD on July of 2004. I didn't get approved until Jan. 2005. My official approval date is July even though I didn't start reiceving benefits until Jan. 2005. So my entitlement date is Jan. 2005. I hope that make sense...

So because I applied within the alloted time for SSD my COBRA was extented. I just got medicare in July of 2006 (2 years for my SSD approval date) and up to that date I have had COBRA coverage.

On a side note SSD and SSI are two different things. SSD is Social Security Disability and Social Security Income. You don't have to qualify for SSI to get COBRA just SSD. SSI is a supplementary income you can get in addition (if you apply for it) to SSD which will give you extra money each month to the SSD. It also allows to automatically qualify for Medicaide to the state welfare department (which with be FULL MEDICAID - meaning no co-pays for doctor visits, or prescritions and you don't have to pay left overs for what they don't cover). Plus if you qualify for that they will cover 3 months past medical bill. It's a definite to apply for. But again no nessary for COBRA.

Anyway. I hope I clarified what I mean't earlier. Let me know if you have more information or stuff I can ready (as you can probably I'm totally insterested in this stuff).

Thanks,

Rachel

[Sunfish]

hi rachel -

you pretty much detailed my current understanding of things. i have done a lot of reading, research & talking with folks myself and when still in grad school did some research papers/presentations on related things as well (COBRA, FMLA, ADA, SSI/SSDI, etc.)

i have insurance now through my former employer that is actually not COBRA as it is included in my LTD benefits. it's a great benefit but it essentially replaces COBRA in that it runs concurrently. thus....when it runs out i don't have any "extra" COBRA time remaining as i had to stop working in december 2004. i applied for SSDI in june of 05 and am still going through the process; i moved from one state to another in the midst of the process which didn't help the situation.

but from my understanding as well as gleaning from what you said, simply applying for SSDI won't get COBRA extended; i actually need to be approved. my current insurance already covers me until the time when i should be getting medicare if/when my SSDI approval comes through (next June) not sure if i'm explaining clearly or not...

so essentially if i don't get approved now i will have to wait for a hearing; i have no doubt that i will be approved then but i can't wait the 2.5 yrs it takes in my area of ohio. i'm dependent on IV nutrition & hydration and without health insurance there is no way to pay for it. so without trying to be melodramatic it may be a matter of life or death for me.

i'm not eligible for ssi as my disability income (through former employer) is just above the threshholds. don't get me wrong...i'm thankful for the LTD income, but it may put me in a tight spot come next year. i may become eligible for some medicaid "spend down" but it's not something that can be pursued until i actually lose my insurance. and my body won't be able to sustain itself for long in that situation.

ggggggggrrrrrrrrrrr. sorry if i'm being repetitive & i do appreciate your trying to help. i feel badly that you spent so much time explaining things that aren't really new to me, but i'll definitely give the EBLA # a ring as i haven't talked to anyone there yet. i'm hoping & praying that i'm approved this time around as then there won't be an issue for me to contend with but it's a pretty scary predicament to be in and i can't wait until it (perhaps) happens to figure out a game plan.

melissa

[deeplyset]

Melissa,

I would also suggest contacting your local Center for Independent Living they specialize in helping people with disablities get the help they need and all the resources avalible to them. You mention your were in Ohio - here is the website for the Dayton Ohio one - http://www.acils.com/ (they may be able to contact with the one closer to you)

I was denied the first time for the SSD and they did my application for me and because the know the right things to say and don't say in the appeals processes they got my application right through the second time. They are about Advocating for people a making sure they get there needs met.

Mind you it is a Non-profit organization to so they don't cost anything and they really work on your behalf.

I'm all about find resources out there to help us because it's so hard to fight for ourselves when half the time your so sick you just want to give up.

The center for independent living also got me a state funded $5,000 grant to remodify my duplex (with my landlord approval -afterall it was improvements) to make it easier for me to get around when I have to use my wheelchair when I'm really sick. That's how proactive these people are in helping people become self sufficient and finding the resources out. All at not cost for me. They even filled the applications out for me.

[Sunfish]

hello again

yep, the CILs are great resources. we have one that is known nation-wide in toledo (the Ability Center), ohio which is where i grew up, where my parents live now, and where i'll be moving back to within the next 2-3 months. once i move back we are already planning on utilizing them as much as possible....definitely for any possible resources in terms of renovation for our house as my parents' is totally inaccessible...no full bath downstairs, no rooms with doors, etc. we can't pursue that until i actually move home though b/c of residency requirements. ah red tape. that's awesome though that you got the grant that you did.

as far as my SSDI goes, i actually have an attorney that - in a roundabout way - i don't have to pay for. details aside, it's also a part of my LTD benefits (but i was able to chose who to hire). so...i have people who know how to write the "right stuff" on the forms at this point too, do the paperwork & phone calls, etc.

melissa

[deeplyset]

Melissa,

Wow. That's awesome. It's seems like you have your ducks in a row and that it's just matter of waiting it out... ??? Right? I'm so sorry.

I hope it works out and that you can get it put though. I know it will help out a lot. I guess I've just been really blessed that I didn't have to go through all of that.

It helps to talk to other people because it makes you count your blessings.

Hopefully our conversation will be helpfully to others if nothing else.

Go luck. And God be with you.

[Sunfish]

rachel -

my thoughts exactly....that this will be a very helpful thread for folks using the search engine later on.

i'm glad things worked out for you & i'll definitely be letting people know how & when things (hopefully) get worked out on my end. i'm in the waiting game now for most if not all parts of my life....definitely testing my patience!

melissa

[deeplyset]

Melissa,

I hear you with that one, the waiting game . Patience is prefect perseverence. I'm excited to hear it all work out for you. Good luck.

Rachel