Question
What is the name of your state?
James Snyder
Florida
So here is my situation, I bought a policy from bcbsfl. I had sprained my shoulder a few months before. By the treating doctors notes on it, it was a "minor" sprain. I was told that there would be a rider on the policy that if I were to have the same injury it would not be covered. I agreed to this. About a week later an agent shows up at my house with a stack of papers to sign including in his words "the rider we discussed". Unfortunately I did not read as carefully as I should have. As it turns out I signed a rider that excluded anything at all to my left shoulder. A year ago I dislocated my shoulder at which point I found out that part of my body is not covered by the policy. Can an insurance company really exclude an entire body part from a policy because of a minor sprain? And even though I signed the rider, I feel that I was misled and want to know if I have any case at all to claim bad faith. It has been more than a year and my credit is most likely shot because of this, should I keep fighting them, or give in and pay?What is the name of your state?
Answer
You have the right to receive a copy of your insurance policy and forms signed by yourself, and you have the right to appeal any denied claim.
You have the responsibility to read and understand your policy. You have the responsibility to know what your policy excludes.
Individual health insurance policies may not exclude pre-existing conditions for more than 12 months,...,and may relate only to conditions that manifested themselves during the 6-month period prior to coverage.
When did you purchase the policy? (month, year)
When did you sprain your shoulder?
When did you dislocate your shoulder?
Answer
Thank you so much for getting back to me so quickly. And if what you say is true than you just made my day.
The rider for the policy was signed on april 19th 2004 and the policy went into effect on may 1st 2004. The injury was in febuary of that year so the rider would be valid but the dislocation of my shoulder did not happen till the end of may 2005. Not sure the exact date but it would have been somewhere in the 26th to 28th range. This puts it more than a year after the policy started. I have been getting the run around from the insurance company for more than a year now, so how do you recommend my going about prosueing this further?
Thanks again.
James
Answer
moburkes, are you certain that the one year limitation on pre-ex includes individual policies? I'm not saying you're wrong, but I'm not 100% certain you're right, either. My understanding was that that portion of HIPAA only applied to group policies; is there a state law I'm missing?
OP, my suggestion would be to go through the insurance carrier's appeal process, and if you're still unhappy with the results, talk to the state insurance commission. I'm not certain bad faith applies here.
Answer
Nope, not sure. I copied it off the department of insurance's website, in the health insurance consumer guide. I just re-typed what was there, since I couldn't cut-and-paste it. Where the ellipses is, I left out a small part that wasn't relavent to OP's particular situation. I haven't written a health insurance policy in years, and never in FL, so that's why I looked it up there.
CRAP, cbg, I copied the wrong thing. OP, I apologize. I didn't mean to make that mistake, and get your hopes up. This is what I was supposed to have copied:
Its point #46a on page 32 of 44.
Individual health policies may not exclude pre-existing conditions for more than 24 months and may relate only to conditions that manifested themselves during the 24-month period before coverage. However, the policy may exclude coverage for named or specific conditions without any time limit.
SSSOOORRRRRRRYYYY! I really didn't mean to make that mistake.
Answer
Nope, not sure. I copied it off the department of insurance's website, in the health insurance consumer guide. I just re-typed what was there, since I couldn't cut-and-paste it. Where the ellipses is, I left out a small part that wasn't relavent to OP's particular situation. I haven't written a health insurance policy in years, and never in FL, so that's why I looked it up there.
CRAP, cbg, I copied the wrong thing. OP, I apologize. I didn't mean to make that mistake, and get your hopes up. This is what I was supposed to have copied:
Its point #46a on page 32 of 44.
Individual health policies may not exclude pre-existing conditions for more than 24 months and may relate only to conditions that manifested themselves during the 24-month period before coverage. However, the policy may exclude coverage for named or specific conditions without any time limit.
SSSOOORRRRRRRYYYY! I really didn't mean to make that mistake.
You got the correct info now. I worked for an ins. co. that issued individual policies, life, health, etc. re health ins. - we could exclude a specific medical problem from coverage w/o any time limit.
Answer
And if you signed a rider excluding the entire body part, then unfortunately you have no one to blame but yourself, because it appears to be a legal policy.