Question
What is the name of your state? Illinois
For the last 3 years, we did not have health insurance. Now that we do (as of May 2006) the insurance company doesn_t want to pay claims due to preexisting conditions. We have appealed the ruling twice. We can_t afford to pay for the insurance AND the medical bills.
It doesn_t seem fair that we are punished for NOT having prior insurance coverage. It was bad enough we had to pay the medical bills.
Is there anyway around this?
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You should have read the policy before purchasing it. What exactly does the pre-existing clause say?
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I was hoping for help, not criticism. We didn't really have a choice in "purchasing" it. It is the only choice provided by my husband's company.
Basically it states that "if a member receives medical advice, diagnosis, care or treatment for an illness or injury within six consecutive months ending on the member's enrollment date, the illness or injury is considered "pre-existing" condition. This plan has an exclusion for Pre-Existing Conditions."
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Even if you did not have insurance for 3 years, when you applied or submitted a claim into your current insurance company, they probably sent for your medical records. If you ever saw the Doctor for the problem OR if the problem/condition/illness is listed in your medical history taken by the Doctor, then the insurance company may consider it "pre-existing".
Ecmst12 is correct with regard to reading your policy and pre-existing clause. It is extremely important that the consumer read and understand the "fine print". Good luck.
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And how long is the exclusion in force for? Most policies will not exclude pre-existing conditions forever, there is usually a waiting period of 6 months or a year before these conditions will be covered. So you can wait until that period is up before having any expensive treatments for these conditions (so long as it will not be detrimental to your health) or you can pay out of pocket. The exclusion only applies to conditions that you were treated for or seen by a doctor for in the 6 months prior to your effective date, so if it's been longer then that, the exclusion won't apply.
It's odd that this policy even has this exclusion, in my experience, it's rare for an employer-sponsored plan to have a pre-existing limitation. Reason being that it can cost more in terms of the man hours required to investigate these conditions then it would save the company in claim denials. That's why I assumed it was a privately owned policy that you purchased yourself.
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The clause is for one year. There are ongoing treatments needed for both myself and my daughter that are necessary and cannot be postponed. We can really rack up a lot of bills in one year.
The insurance company is Fiserv Health. I have read the policy. I am not an idiot. That's why I am asking if there is any way around the clause. I just don't understand why we are being punished for being previously uninsured. Isn't there a law or loophole to protect us?
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No one called you an idiot.
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You are not being punished, the insurance company is merely trying to protect their interests. Otherwise what is to stop people from going on the insurance just because they need a treatment or surgery and then cancelling it right after(or at the next open enrollment)? They would have to pay out a lot of money and not have a chance to recoup any of it through your premium payments.
There is no way around the limitation though. The only condition that can't be considered pre-existing for an employer sponsored plan is pregnancy. The only people who can't be held to a pre-existing limitations are newborn babies (added within 30 days of birth) or newly adopted children (added within 30 days of adoption). You will just have to wait out the exclusion. If you have a healthcare spending account, you can pay your excluded medical bills out of that. If you don't, you can deduct the expenses from your taxes if you file an itemized return.
The law that protects you is the one that says the pre-existing limitation can only apply to conditions treated no more than 6 months prior to enrollment and last for no longer than 12 months after enrollment.
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To ecmst12: Thanks for the information. While I don't like the answer, this does answer what I was asking.
To lealea1005: The reason I stated I wasn't an idiot is because of the condescending tone of the replies.
I'm guessing you both work for insurance companies.
Thanks.
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Nope, I don't work for an insurance company. Although I have no idea how you could have taken my reply as condescending, I apologize for the misunderstanding. Have a good day.
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I used to work for an insurance company(7 years health insurance experience with 3 different carriers), I don't anymore, but I do still believe that it's each person's responsibility to read and understand their benefits *before* having any services done. I agree that the pre-existing limitations suck, but until we get national health care in this country, health insurance is still a business and they need to make money in order to be able to keep providing benefits for you.
For the future though, if you know you have ongoing medical problems, it's important to not let your coverage lapse for any significant amount of time in order to avoid being subject to these limitations. The break in coverage has to be at least 63 days in order for a pre-existing limitation to apply; shorter breaks are ok.
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I don't work for an insurance company either but I have administered employer sponsored benefit plans for 25 years.
No, there is no way around the clause. The policy is what the policy is.