Pre-existing condition technicality
October 12, 2011 8:59 AM Subscribe
My wife just purchased health insurance for herself. Today is her first day of coverage. She has been experiencing back pain and nerve pain in her leg for the better part of a week, however. If she goes to the doctor today and they send her for an MRI (which we're certain they will) and subsequently decide to do surgery (we think she has a slipped/bulging/herniated disc) is there a chance the claims processor at the insurance company will question paying for any of these services?
She has not been seen for back problems in the last 6 months (that's the insurance company's look-back time frame), but we're worried to walk into a doctor's office on her first day of coverage, say she's had a problem for a week and expect to have our claims paid. Is it possible they'll look at her back problem as an issue she should have sought treatment for last week and as a result not pay for any visits/procedures/surgeries pertaining to this "preexisting condition"? Our other option is a cobra policy she could pay $655.87/month out of pocket for from her most recent employer where she was laid off in August. However, we'd have to pay for September and October, so we're looking at $1300 just to get coverage we know won't deny her. What should we do?
She has not been seen for back problems in the last 6 months (that's the insurance company's look-back time frame), but we're worried to walk into a doctor's office on her first day of coverage, say she's had a problem for a week and expect to have our claims paid. Is it possible they'll look at her back problem as an issue she should have sought treatment for last week and as a result not pay for any visits/procedures/surgeries pertaining to this "preexisting condition"? Our other option is a cobra policy she could pay $655.87/month out of pocket for from her most recent employer where she was laid off in August. However, we'd have to pay for September and October, so we're looking at $1300 just to get coverage we know won't deny her. What should we do?
Seconding HeyAllie.
posted by amazingstill at 9:10 AM on October 12, 2011
posted by amazingstill at 9:10 AM on October 12, 2011
Quick web search gave this..
I seem to remember the debate about pre-existing conditions wrapped up in the whole health plan thing, but HeyAllie's suggestion is still the best. But hopefully the link will provide some insight as well.
posted by rich at 9:18 AM on October 12, 2011
I seem to remember the debate about pre-existing conditions wrapped up in the whole health plan thing, but HeyAllie's suggestion is still the best. But hopefully the link will provide some insight as well.
posted by rich at 9:18 AM on October 12, 2011
You will need to call the health insurance company and speak to someone about what to expect for your wife based on what kind of coverage you have.
But you should also prepare yourself for a situation where nobody at the health insurance company will give you a straight yes/no answer over the phone.
posted by holgate at 9:19 AM on October 12, 2011 [4 favorites]
But you should also prepare yourself for a situation where nobody at the health insurance company will give you a straight yes/no answer over the phone.
posted by holgate at 9:19 AM on October 12, 2011 [4 favorites]
The pre-existing language in every health plan I've ever had has always defined pre-existing as something you had treated in the previous X months, or something that you knew about within the same time frame, or something that accepted medical practice would have suggested treatment for within the previous X months. In other words, they specifically negate any attempt to wait until you have insurance to have something treated.
posted by COD at 9:27 AM on October 12, 2011 [1 favorite]
posted by COD at 9:27 AM on October 12, 2011 [1 favorite]
Every response suggesting you call, get confirmation and/or read the fine print is correct. A general/global/non specific answer is if the COBRA coverage is part of a group plan and you qualify for reinstatement then appropriate claims will probably be paid. If the new insurance is an individual plan it will probably not be covered. You need to personally check this out before committing this much present and potential money. Also, wwhen discussing this with insurers be open and candid about any precondition--they will quickly see through anything but the most sophisticated of misstatements . They have the advantage of looking at hundreds of thousands of procedures, enrollment dates, etc. Plus--any decent history is going to reveal when the symptoms started, etc.
posted by rmhsinc at 9:38 AM on October 12, 2011
posted by rmhsinc at 9:38 AM on October 12, 2011
I'd call my doctor and schedule a physical. At the appt., ideally, this week or next, you can discuss the pain. I'd also pay the cobra so that you have uninterrupted coverage. It's a lot of money, but a lot less than getting stiffed for an MRI. It could be non-surgical, like sciatic pain, so don't overthink the plate-o-beans.
posted by theora55 at 9:56 AM on October 12, 2011 [1 favorite]
posted by theora55 at 9:56 AM on October 12, 2011 [1 favorite]
I work in a medical billing office and in my experience, yes, this is likely a risk she would be taking if she tells the doc that she has been having this pain since before the policy started. But it's impossible to say for sure without knowing the specifics of her policy.
I would call the insurance company and get, in writing, and without specifying the particular situation, a copy of the pre-existing condition stipulations. She may even have them already, if the insurance company sent her a benefits packet. Simply talking to someone on the phone is not enough, because when it comes to the finer/more complicated points of a policy's coverage, you are unfortunately likely to get incorrect and varying answers depending on the customer service rep you speak to. If she does just talk to someone instead of getting a written copy, she should document the name of the rep she spoke to as well as the date and time of the call, so that if they record phone calls and she needs to dispute a denial, they can locate the call more easily.
posted by DrGirlfriend at 10:31 AM on October 12, 2011
I would call the insurance company and get, in writing, and without specifying the particular situation, a copy of the pre-existing condition stipulations. She may even have them already, if the insurance company sent her a benefits packet. Simply talking to someone on the phone is not enough, because when it comes to the finer/more complicated points of a policy's coverage, you are unfortunately likely to get incorrect and varying answers depending on the customer service rep you speak to. If she does just talk to someone instead of getting a written copy, she should document the name of the rep she spoke to as well as the date and time of the call, so that if they record phone calls and she needs to dispute a denial, they can locate the call more easily.
posted by DrGirlfriend at 10:31 AM on October 12, 2011
I'd also consider not worrying about this until you speak with your doctor. Yes, it could be a herniated disc, but most herniated disc-related pain resolves on its own within several weeks using just rest and pain medication. I'm not a primary care doctor, but MRI and surgery are not our usual immediate first steps for a week of back pain unless there are other concerning features (like leg weakness, bowel or bladder incontinence) that would indicate significant spinal cord compression. ianyd... but you might be putting the cart before the horse...
posted by treehorn+bunny at 10:41 AM on October 12, 2011 [1 favorite]
posted by treehorn+bunny at 10:41 AM on October 12, 2011 [1 favorite]
Any way you can pay for just one month of that COBRA? You only need to have had continuous coverage within the last 63 days to meet the old rules.
My understanding of the new rules is that not every plan yet has to ignore all preexisting conditions, that's rolling in over time. There's a pre-existing condition plan setup but you have to be uninsured for 6 months OR get denied.
posted by phearlez at 11:13 AM on October 12, 2011
My understanding of the new rules is that not every plan yet has to ignore all preexisting conditions, that's rolling in over time. There's a pre-existing condition plan setup but you have to be uninsured for 6 months OR get denied.
posted by phearlez at 11:13 AM on October 12, 2011
Response by poster: We opted to continue the COBRA coverage. In no way do we want to attempt to commit fraud and I'd rather pay the money for COBRA than risk having to pay thousands in denied claims from the new insurance company. Thanks for everyone's input, much appreciated.
posted by psiwave at 12:03 PM on October 12, 2011
posted by psiwave at 12:03 PM on October 12, 2011
Well, it sounds like you've resolved what you're going to do, but for future reference: states have different regulations concerning how health insurers are allowed to treat pre-existing conditions. I don't see from your profile where you live, but it's always an option to call up your state Department of Insurance (they almost always have a consumer question line) and ask.
There's a decent overview of state regulations concerning pre-existing conditions at State Health Facts. If you live in one of the states using an "objective standard" for the definition of pre-existing condition, you'd likely be safe as that would require that you'd actually been treated or received medical advice about the condition in order for it to be considered "pre-existing" by any insurer licensed to write insurance in the state. (You would of course want to check this with your state Department of Insurance, which regulates insurers, as websites can be wrong or out-of-date.) On the other hand, if your state has no standard or uses the "prudent person standard" you'd potentially open the door to the insurance company arguing that a prudent person would have sought medical advice for your wife's symptoms and so it would qualify as pre-existing and disqualified from coverage.
And one small note/correction on phearlez's answer above: in order to gain HIPAA portability protections (which prohibit your new insurer from imposing pre-existing condition restrictions as long as you've had 18 months of employer coverage with a gap no longer than 63 days), you generally have to (1) first exhaust your COBRA coverage, which it sounds like you haven't done yet, and (2) enroll into a HIPAA plan--which might be only one or two specific plans offered by each insurer or even just the state high risk pool run by the state, depending on which state you live in.
posted by iminurmefi at 12:21 PM on October 12, 2011
There's a decent overview of state regulations concerning pre-existing conditions at State Health Facts. If you live in one of the states using an "objective standard" for the definition of pre-existing condition, you'd likely be safe as that would require that you'd actually been treated or received medical advice about the condition in order for it to be considered "pre-existing" by any insurer licensed to write insurance in the state. (You would of course want to check this with your state Department of Insurance, which regulates insurers, as websites can be wrong or out-of-date.) On the other hand, if your state has no standard or uses the "prudent person standard" you'd potentially open the door to the insurance company arguing that a prudent person would have sought medical advice for your wife's symptoms and so it would qualify as pre-existing and disqualified from coverage.
And one small note/correction on phearlez's answer above: in order to gain HIPAA portability protections (which prohibit your new insurer from imposing pre-existing condition restrictions as long as you've had 18 months of employer coverage with a gap no longer than 63 days), you generally have to (1) first exhaust your COBRA coverage, which it sounds like you haven't done yet, and (2) enroll into a HIPAA plan--which might be only one or two specific plans offered by each insurer or even just the state high risk pool run by the state, depending on which state you live in.
posted by iminurmefi at 12:21 PM on October 12, 2011
If she can stand it, she should wait a fair buffer period, where one could reasonably say they didn't have symptoms before the policy took effect. A month would be good. Two, even better.
Going in with severe back pain a day after the policy takes effect is like waving a big, skyscraper-sized red flag proclaiming "I have a pre-existing condition!" to the insurer.
posted by Thorzdad at 1:20 PM on October 12, 2011
Going in with severe back pain a day after the policy takes effect is like waving a big, skyscraper-sized red flag proclaiming "I have a pre-existing condition!" to the insurer.
posted by Thorzdad at 1:20 PM on October 12, 2011
This thread is closed to new comments.
You will need to call the health insurance company and speak to someone about what to expect for your wife based on what kind of coverage you have.
posted by HeyAllie at 9:08 AM on October 12, 2011 [1 favorite]