Insurance Pre-Existing Condition Woes

January 30, 2007 6:41 AM

My insurance provider wants me to fill out a pre-existing condition questionnaire! Help!

After not being insured for about 18 months, I've finally started a job that offers me health insurance. Unfortunately, I have a chronic pre-existing condition (colitis) that requires regular medical care... including a colonoscopy every couple of years. Overjoyed with the possibility of not having to pay in full, first thing I do once I'm covered is run and get a colonoscopy.

But along comes a bill for $930 and a pre-existing condition questionnaire. My question is--is there anything I can do to get them to cover me? I'm in over my head here. I have a couple thousand dollars worth of bills that they're refusing to cover unless I return this questionnaire. But I know once I do, they'll probably refuse to cover me anyway. My only hope is you, hive mind, to help me do this an intelligently as possible.

I think my only glimmer of hope is that the GI that was treating me before being insured has completely quit his practice and has absconded with all my medical records. Nobody, myself and even his old hospital, knows where to find him or how to contact him. Would it be a bad idea to just leave him off the questionnaire entirely?

I don't know if it makes a difference, but I'm currently located in NYC.

Thanks for your help in advance!

posted by kmtiszen to health & fitness (18 comments total)

Don't lie about this. Usually the drill is that they will not cover pre-existing conditions for something like two years. Ask your new employer. If you lie, and they find out, then they can deny you coverage even a long time later. It might also be considered insurance fraud (I am completely unsure about this). You would be surprised at what records are kept on computers these days and how they are shared. Did you ever submit an insurance claim related to your colitis, even to a different insurer? If so, they likely know.
posted by caddis at 6:54 AM on January 30, 2007

If you are working for a reasonably large company their contract with the insurer may override the standard pre-existing condition clauses. You may want to check with HR.
posted by COD at 7:00 AM on January 30, 2007

Don't commit insurance fraud. The intelligent thing to do is to be honest.
posted by dmt at 7:01 AM on January 30, 2007

Unfortunately, Caddis is correct.
If you ever previously entered a claim, no matter how small, for your condition, it's in the system. And by "system" I mean that whatever insurer you are with now will have access to those claims records.

Be glad you're at least part of a group plan. Imagine having to pay those colonoscopy bills AND your monthly premiums, as you would have to do with a private account.
posted by Thorzdad at 7:07 AM on January 30, 2007

Urgh. Stupid pre-existing conditions and "continuing coverage." This is why I'm paying almost $1500 for two months of COBRA coverage while I'm between jobs.
posted by cebailey at 7:08 AM on January 30, 2007

Yeah -- what COD says. They might just be trying to flim-flam you.
posted by contessa at 7:08 AM on January 30, 2007

By the way, when I said I was not sure whether it was insurance fraud to lie about a pre-existing condition I meant I was not sure if it was criminal insurance fraud. Lying to obtain coverage is certainly fraud, and grounds for canceling your coverage (the insurance company's favorite trick, even when you were trying to be truthful). I just don't know whether that is a gross enough violation to trigger criminal penalties. Of course insurance fraud is quite common. An acquaintance who is an insurance adjuster once remarked about the odd coincidence of almost every stolen car just happening to have a set of Pings in the trunk.
posted by caddis at 7:21 AM on January 30, 2007

Lying to obtain coverage is certainly fraud, and grounds for canceling your coverage (the insurance company's favorite trick, even when you were trying to be truthful).

And also grounds for demanding repayment, plus interest. "Getting away" with it is not a one-time event - it hangs over you head for a long time.
posted by phearlez at 7:32 AM on January 30, 2007

Thanks for your input, everyone. This is my first go-around with this and it's a pretty stressful situation. There's no way in hell I could afford to pay these bills coming my way.

I've submitted the pre-existing condition questionnaire and answered the questions as honestly as possible. Don't want to get caught up in anything that'll put me in more over my head than I already am. But c'mon--the real crime here is refusing to cover my pre-existing condition. I understand the business of it all, but it really is a disgusting practice.

Thanks again!
posted by kmtiszen at 8:16 AM on January 30, 2007

Definitely agreeing with everyone who says don't lie and don't commit insurance fraud.
However:
Sometimes the definition of pre-existing condition varies from insurer to insurer. Look at the policy to find out the exact wording. It may be the case that if you haven't been *treated* for the condition in a certain amount of time, it's not considered a pre-existing for these purposes.
Since you say your colitis requires regular medical care, chances are you'll still be on the hook (i.e., you will have been treated within the relevant period), but it's at least worth checking.
posted by katemonster at 8:17 AM on January 30, 2007

Ack! Check out this page.

It'll tell you all about what's legal when acquiring new coverage and what's not.

As far as your pre-existing condition... I know nothing abot colitis. But if you haven't been doing anything about it for the time you were uninsured because you couldn't afford it, read the following:

"What is a preexisting condition?

A preexisting condition is a medical condition present before your enrollment date in any new group health plan.

Under HIPAA, the only preexisting conditions that may be excluded under a preexisting condition exclusion are those for which medical advise, diagnosis, care or treatment was recommended or received within the 6-month period before your enrollment date. (Your enrollment date is your first day of coverage, or if there is a waiting period to get into the plan, the first day of the waiting period.)

If you had a medical condition in the past, but have not received any medical advise, diagnosis, care or treatment within the 6 months prior to your enrollment date in the plan, your old condition is not a preexisting condition to which an exclusion can be applied. "

If you didn't seek treatment for your condition, didn't take medicine, speak to a doctor, anything for six months, they cannot deny your coverage no matter what you put on that form. You may have to fight tooth and nail for it now that you've put put it on a form, but the law is on your side if this is your case.

If you did get treatment during the prior six months, of course that won't help... But the law also says that even though you were uninsured for 18 months before becoming insured, they can only deny coverage of your pre-existing condition for 12 more months (18 months if you didn't take insurance when it was first offered to you, but it sounds like you did). After that, they have to start paying your bills.

Anyhow, this is federal law. They must adhere to this. This law is there, to a certain extent, to protect people in your situation.
posted by FortyT-wo at 8:52 AM on January 30, 2007

And by "system" I mean that whatever insurer you are with now will have access to those claims records.

By what method, exactly? The Medical Information Bureau is the only method I know of in the US, and you can request your actual report -- which contains nowhere near your full claims history.
posted by trevyn at 9:44 AM on January 30, 2007

First things first, I would go and speak with your HR department. If you are with a big company, they should be able to answer your questions (don't tell them you're deciding whether to lie on the questionaire, obviously, but tell them you want to know what the deal is on pre-existing conditions), and if it's a small company, they can give you the contact info for your insurance agent / salesperson, who is supposed to be on your side.

Most bigger companies that I've worked for, have had agreements in place that I thought ensured coverage for pre-existing conditions (although I've never had to deal with it personally). You might have a way out.

Anyway, I just think you should make sure to exhaust your options there before doing anything questionable/rash.

Personally, I don't think you have any "moral" obligation to be honest to an insurance company on something like this, because they're scumbags anyway, and will deny you coverage if given any opportunity. What it boils down to is straightforward risk/benefit analysis. (Which I think dictates that lying is a bad idea, because it could come back to haunt you later. But in the absence of that, I wouldn't give them any quarter, because they're not going to give you any.)
posted by Kadin2048 at 11:32 AM on January 30, 2007

FortyT-wo gives me hope for a similar situation I'm about to be in. (Also colitis, by the way. Stupid intestines.) I've been uninsured for a year, but also haven't had a doctor's appointment in that time. If that allows me to get around the pre-exisitng condition restriction it will be a huge relief.
posted by MsMolly at 12:30 PM on January 30, 2007

Read FortyT-wo's HIPAA link. It should answer your questions.

The important thing from here on out is to keep your insurance coverage continuous, even if you find yourself between jobs in the future. So long as you don't go without coverage, another group plan can't deny you coverage. Individual plans are another story.

As for your current situation, if they deny coverage for the colonscopy, you can always appeal it. The end result may be the same, but it can't hurt to try. And I'd still let your health care providers bill the insurance company before billing you, even if it's something you're sure they'll deny.

I know how frustrating (and expensive) the whole thing can be. Having health issues is stressful enough without the added worry of how you'll pay for it. Don't deny yourself any necessary treatments or procedures because the insurance won't cover it. If you need it, you need it. Most doctors, hospitals, etc. will work out a payment plan with you if you're footing the bill yourself.
posted by curie at 1:26 PM on January 30, 2007

I'd like to second also working with your HR on this -- tell them something along the lines of 'hope me please! My understanding of federal law & our medical insurances is [that stuff FortyT-wo put up above & anything you can find about pre-existing conditions in your medical benefits papers]. I went and did that & they sent me this -- can you help me sort it out or point me towards someone who can?"

I just got way over billed on something the insurance company was telling my doc's office & me that they didn't cover, but it sure looked like it in my benefits, so I sent it to HR & they sent it on to the benefits reps that they buy the insurance from & word came back really quick that said insurance was remitting full payment to my doc & I was off the hook.

Good luck on this. Dealing with insurance sucks.
posted by susanbeeswax at 10:15 PM on January 30, 2007

The important thing from here on out is to keep your insurance coverage continuous, even if you find yourself between jobs in the future. So long as you don't go without coverage, another group plan can't deny you coverage.

And the important thing to remember when arranging that is that the definition of "coverage" is generous. You can buy the cheapest bare-ass minimum catastrophe coverage and satisfy the continuous (no lapses over 62 days) requirement.

There's a large number of plans that can be bought in the under $100 range if you're under 40, as the majority of MeFi is.
posted by phearlez at 8:25 AM on January 31, 2007

But most are unavailable to those with pre-existing conditions like me and the OP. And when you're unemployed it's hard to find the $400/month to pay for COBRA, which is why we find ourselves in situations like this.
posted by MsMolly at 5:10 PM on January 31, 2007