Question
My coverage with Pacificare PPO began on 7/1. On 8/3, I was diagnosed with cancer. I am only 24 yrs old. Lucky for me, the tumor was discovered early. But during this time, I saw many doctors and had many tests performed. PacifiCare refused coverage for many of them stating that I had a pre-existing condition. I have appealed and have sent them numerous documentation including Certificate of Coverage, doctor's letter stating date of diagnosis, list of doctors I've seen this year, etc. Yet, PacifiCare still refuses my claim because of a pre-existing condition. Before being diagnosed with cancer, I've been healthy with no previous medical conditions. What can I do?
What is the name of your state? CA
Answer
Okay. Some questions.
What treatments, tests, doctor's visits had you had PRIOR to your diagnosis?
For what time period (from what date to what date) do you have creditable coverage?
Congrats on finding the cancer early. Good luck.
Answer
Originally Posted by jenjen31
uuuhhhmmm, you spelled perfectionist wrong.
Oh, brother....
Answer
Originally Posted by jenjen31
uuuhhhmmm, you spelled perfectionist wrong.
Oh, brother....
Exactly. That's what I said, and that's why I kept it!!!!
Answer
Another pertinent question for the OP; is your coverage with Pacificare a private, individual policy or is it an employer-sponsored group policy which you obtained through your employment?
Answer
Okay. Some questions.
What treatments, tests, doctor's visits had you had PRIOR to your diagnosis?
For what time period (from what date to what date) do you have creditable coverage?
Congrats on finding the cancer early. Good luck.
I've had no treatments prior to diagnosis. The last time I saw a doctor before 7/1/06 was the year before on 8/2/05 for an annual ob/gyn exam. Then I saw an obgyn on 7/1/06 who said I had a breast cyst and recommended a surgeon to get it aspirated. I went to the surgeon on 7/13/06 and she recommended surgery since it wasn't a cyst. So on 7/29/06, I had an operation since I had PPO, I didn't get approval. And on 8/3/06, I was diagnosed with cancer.
I had creditable coverage until 3/06 when I took another job. So for 4 months, I didn't have insurance. The insurance is an employer-sponsored group policy that I obtained through my employment.
Thank you very much for the help.
Answer
Okay. What pre-existing condition, then, are they using to deny payments. What doctor's visit, test, etc are they referring to?
You need to contact the department of insurance.
Answer
The four month gap is long enough so that they can legally invoke a pre-ex clause.
However, there has to be a pre-ex condition for them to invoke it. I agree with moburkes that we need to know specifically what they are referring to.
There has to be an appeal procedure. You need to find out what that is and go through it. When that procedure is complete, if they are still claiming pre-ex, then I would agree that the department of insurance is your next step.
Answer
Okay. What pre-existing condition, then, are they using to deny payments. What doctor's visit, test, etc are they referring to?
You need to contact the department of insurance.
I'm assuming the pre-existing is my cancer. I can't tell by looking at the claims PacifiCare denies. They paid for my ob/gyn visit, 1 surgery (the 3rd one), 1 pathology laboratory testing, PET/CT scan, and all my oncologist's visits. But refused the first two operations, my visits to my surgeon, 4 pathology laboratory testing, and a visit with another doctor for a 2nd opinion. All are cancer related. I think there is more but I can't log into their website. I will call PacifiCare in the morning and see what their appeals process is.
Can PacifiCare really evoke pre-existing condition when I had nothing wrong with me before I was diagnosed? This is all so confusing.
What do I do when I contact the Dept of Insurance? I'm sorry. I'm so new at this. The last thing I expected was to deal with my insurance.
Thank you again everyone for your advice.
Answer
Can PacifiCare really evoke pre-existing condition when I had nothing wrong with me before I was diagnosed? This is all so confusing.
NO, pre-existing condition would only apply if you were diagnosed or treated prior to your coverage becoming effective. So this condition is NOT pre-existing and they need to explain to you why they think it is, so you can offer proof to the contrary. If they refuse to overturn the denial after presented with proof that the condition was NOT pre-existing, that's when you contact the department of insurance for assistence.