Pre-existing condition waiting period?
May 15, 2008 4:12 AM   Subscribe

(USA filter) I just got health insurance, Yeah! But I just got a letter that I have to wait a year before they will pay for something that diagnosis "should have been" received before the effective date of my policy.

So does that mean if I have tests that show that a cancer probably started two months ago, I'm screwed? So this means I shouldn't have any tests for a year??

I feel fine but I really want to have the tests that I am supposed to be getting for my age. I just feel devastated.
posted by anonymous to Health & Fitness (8 answers total) 3 users marked this as a favorite
If this is employer-supplied health insurance, talk with your human resources office.
posted by Carol Anne at 4:41 AM on May 15, 2008

Most, if not all health insurance and life insurance plans have a one or two year exclusion clause. The onus is on you and your doctors to prove that whatever is wrong with you could not possibly have STARTED within that timeframe. Not being detectable within that timeframe is not going to qualify you. That said, which is more important to you, your health or your money?
posted by Gungho at 4:45 AM on May 15, 2008

It sounds like your insurer (or perhaps the whole industry) had an issue with people avoiding the pre-existing condition limits by avoiding medical advice. An uninsured person who broke his finger might buy some insurance, wait a month, and then go to the doctor. ("This finger has hurt like crazy for two weeks!")

Similar catch-22: most pre-existing condition rules restrict maternity coverage for the first nine months. Suppose you get insurance, get pregnant a month later, and have a preemie at seven months. Will the insurer cover the delivery? Clearly they should, but you can certainly imagine it ending up in court.

If you've bought decent insurance, and you don't plan to defraud them, you don't need to be afraid of this particular rule. If you have something specific worrying you, call them.
posted by fantabulous timewaster at 4:49 AM on May 15, 2008

I'm guessing there was a substantial gap in time between now and the last time you had health insurance, or you have moved from a employer-provided group plan to a private plan. In either case, pre-existing conditions can be excluded from coverage by your new plan. Usually what happens is the new insurer excludes coverage for a period of a year. This means that, if you experience a recurrence of any excluded condition during that one-year period, they will not cover treatment.

The "should have been received" bit is a little strange. What it sounds like is that the insurer might have requested confirmation of a diagnosis from a doctor and never got anything back, so they assume the worst and are excluding coverage for whatever they feel you were being treated for. At least that's how I read it, FWIW.

And, I second hal_c_on about contacting the insurer to get the right answer.
posted by Thorzdad at 4:57 AM on May 15, 2008

Generally, if you've been covered by another insurance plan before switching to a new one, you can credit that coverage towards the preexisting condition exclusion. So if you had insurance for six months before this new insurance, your preexisting condition exclusion would be six months shorter -- if you had insurance for a year, then the exclusion period wouldn't apply at all in your case.

The idea is to discourage people from waiting around until they're sick to get insurance. Since the insurance companies need income from lots of mostly healthy people to offset the cost of coverage for the few sick people, if everyone waits to get coverage, the plan will become insolvent.

Unfortunately, this means that people in situations like yours (presumably you are newly insured -- that's what it sounds like from your post, anyway) find themselves in this position. But, if you did have insurance up until now, then you probably don't need to worry about this.
posted by dseaton at 4:58 AM on May 15, 2008

OK, so. Speaking as someone who used to do customer service and claims processing in the industry for a living (thank heaven I don't anymore)...

Denial of pre-existing conditions is, despite what a lot of people like to think, simply an enforcement of the way insurance is "supposed" to work: insurance is, basically, an amortization of a large expense. In the case of health insurance, your monthly premium allows you to spread the potential cost of medical care out over an extended period of time, rather than taking the hit all at once. But just as you wouldn't be able to get useful coverage for an auto accident after the accident occurs (since the idea would be that the cost is spread out by your payment of premiums prior to the accident), you typically can't pick up useful health insurance after you already have an expensive condition. The way this actually works, however, is somewhat complex.

First up, there are a couple of important bits of information which can change your situation:

1. From the way you've worded your question I'm assuming you did not previously have any form of health insurance, but if you did that can dramatically alter or even eliminate the ability of your new insurer to deny coverage for pre-existing conditions. If you had previous coverage, and the lapse between the end of that coverage and the start of your current coverage was less than 63 days, you need to contact the previous insurer and ask for a "certificate of creditable coverage" which you can present to the new insurer.

2. Exclusions for pre-existing conditions can only be applied by "looking back" over a recent stretch of your medical history. How recent will vary with the type of plan (individual private insurance versus group employee insurance) and how precisely you enrolled, but typically is between six months and one year.

As for what can be denied and what can't:

3. On many types of plans some conditions, as a matter of US federal law and assorted state laws, can never be considered pre-existing for any reason whatsoever. Mostly, this is pregnancy and pregnancy-related conditions.

4. Your insurer is permitted to request copies of your medical records for the period in which they're allowed to "look back" over your history. Typically this means you must provide to them the names and addresses of any doctors or hospitals in which you were treated during that period, and you may need to sign an authorization for them to obtain the records.

5. In order to deny a condition as pre-existing, the insurer must obtain documented evidence that you were actively receiving medical advice or treatment for that specific condition (typically, as shown by the ICD-9/ICD-10 diagnosis codes on the records) during the period in which they're allowed to look. If no such evidence exists, they cannot deny coverage for that condition. Similarly, they cannot simply issue a blanket denial of all coverage. Note, however, that attempting to hide relevant records from the insurer may constitute insurance fraud in some jurisdictions.

6. Private insurance plans typically have a battery of screening questions or possibly even medical exams prior to allowing you to enroll (group plans offered through an employer are not permitted to do this, and must offer the same coverage to all employees in the group). Your policy will, in that case, be contingent on your truthfulness in answering those questions or undergoing the screening exam, and if you concealed information or misled them it is typically grounds for termination of coverage.

7. Sometimes the wording of a denial notice is misleading; many people will see the phrase "pre-existing condition" and jump to a conclusion when, in fact, the claim is merely being temporarily denied pending receipt of records which will show whether the condition is technically pre-existing. Moral of the story: carefully read everything the insurer sends you, and don't hesitate to call them with question.

8. If you think something fishy is going on that the insurer can't explain sufficiently, open up the phone book and call the office of your state insurance commissioner. They'll be able to give you specific advice for your situation and will have detailed knowledge of relevant federal and state regulations which can apply to you.
posted by ubernostrum at 5:28 AM on May 15, 2008 [10 favorites]

I was going to say something but was pre-empted by ubernostrum's detailed and knowledgeable response. The only other thing I can add is that where you and your employer are matters a lot, since some state laws make things more difficult to obtain coverage than others.

It doesn't sound like there is any specific condition you are concerned about, but- speaking from experience- if there is, you need to be prepared for the insurer to pull every dirty trick in the book.
posted by foxy_hedgehog at 5:58 AM on May 15, 2008

So does that mean if I have tests that show that a cancer probably started two months ago, I'm screwed? So this means I shouldn't have any tests for a year??

The worst thing that will happen is they can deny coverage on a particular condition for a year.

So waiting a year for testing won't help. All that does is guarantee you'll wait a year for any treatment. If you get tested now, you have (at bare minimum) a fighting chance of getting treatment covered now.

So you don't lose anything by getting tested now and don't gain anything by waiting a year for testing.
posted by flug at 3:55 PM on May 15, 2008

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