Question
What is the name of your state? Ohio
thank you for your time.
my name is francis. i'm 30, male. in late october 2005 i bought health insurance from assurant health/meidcal mutual of ohio. i had a back problem in october, and went to the neurologist in early november. i submitted the visit to my new insurance, fully expecting it to get denied because i had back pain previous to the visit. i just figured it would buy me time to get the money together for the visit itself. it didn't really matter, because by the time i went to see the neurologist my back was feeling fine, so i wasn't really worried about it.
however, a little less than a week later, something else happened. i noticed one night my left ankle was swollen very huge, and the veins were popping out of my leg. i went to the ER, and got a bunk diagnosis. a month later i had a follow-up visit and the doctor ordered an ultrasound of my legs. turns out i had extensive DVTs. i was admitted immediately, and they discovered i had a pulmonary embolism as well.
currently i'm just fine. i'm on the mend. with some extensive scanning and blood work they found i had a genetic blood disorder that makes me clot more than a normal person. they also found i have some birth defects in my venous system that may have contributed to the clotting. all in all, i should be fine, but i will probably be a lifer on anti-coagulation therapy, and may have the occasional hospital admission due to high or low blood "thin-ness"
now, i was really pleased by the fortune of having bought insurance before any of this happened. and all of my docs assurerd me that the idea that any of this being pre-existing is insane. the clots on the ultrasound and the CT scan were diagnosed as "acute" which means at MOST they were a couple of weeks old, clearly putting them within the time frame of me having bought insurance.
however my insurance company told me that since i didn't own any insurance previously (i don't know what that has to do with it. i had just got a decent job and thought i should be responsible about my care), and since i had this neurologist visit, that if they found even the tiniest evidence that i had even a sore muscle before my contract (which isn't hard since i was a professional athlete) they could call my clotting pre-existing.
what can i do at this point? do they have a carte blanche to deny me on such dubious pretexts as a "sore muscle"? my clots were diagnosed as acute, NEW clots. what can i do to prepare myself for a fight, and to force them to honor the policy? all my docs think it's crazy to call it a pre-exist, but it seems likely they're going to. what is my move to get ready in case they do? also, i just got laid off, so i can't afford an attorney. what then?
thank you so much. peace.
Answer
Had you been treated for the back pain or blood clots in the past 12 months prior to getting coverage? If you had symptoms but didn't go to the doctor that's ok. As long as you hadn't been seen by a doctor for these conditions for the 12 months prior to coverage beginning, they're not considered pre-existing conditions.
Answer
Not so fast . . .
I the covered participant had symptoms prior to the effective date that would have prompted a reasonable person to seek medical attention, the later claims can still be denied as pre-ex. Each carrier words their contract differently, but most have some wiggle room concerning pre-ex.
Answer
well, i obviously had back problems before i got the policy. again, as far as i am concerned that is pre-existing, and if the company decides not to pay for the visit to the neurologist to check out my back, that's fine by me. i just figured i'd give it a shot.
the clotting was a seperate unrelated event, however, from the back injury. i clearly threw out my back climbing up a set of stairs carrying a load. the clotting in my deep veins came after.
the hospitalization and clots were a complete surprise. i had never had clotting to my knowledge before, and the whole incident was very frightening. and the first DVTs i had were declared to have started at minimum a good 14 days after my policy was purchased - if not more. close, but as far as i'm concerned that counts. they have to honor the policy. just because it was close doesn't mean it wasn't real. a DVT can hit in about a minute. i was juts lucky i was covered.
but i'm afriad they're going to try and fudge the back pain appointment as an early DVT sign, which is insane, and here is why:
the admission was very costly and very soon after my policy, so the insurance company has already decided i must have known - or even if i didn't, i think they have decided they have a good avenue for denying me. they don't want to pay out.
and truth is, with a DVT, the symptoms are so diffuse that a muscle cramp - shoot, even a fever a couple of years ago could have been a symptom of a DVT i didn't know about. so i feel like, again, even though my docs all agree this was completely out of the blue, and none of us could have guessed or predicted this, that the company is going to try - just because they can.
the standards for pre-exist for assurant health are any condition with symptoms sufficient for suggesting diagnosis or a diagnostic process. i'm not wording that exactly, but that's the gist.
like i said, even a fever is a sign of a DVT. DVTs don't necessarily have pain or swelling. they could call almost anything a previous DVT related symptom and deny me, which is a total abuse of the contract. so, again, where do i start to preempt that kind of dishonerable nonsense? any ideas?
Answer
Well, I don't think they could possibly say that a reasonable non-medical professional would have sought treatment for blood clots because he had back pain....For now, just let them do their investigation. If they end up denying your claim, you can appeal. There are several levels of appeal process that should be described in your policy, up to 3rd party review/mediators, so I wouldn't worry about lawyers or anything unless all those avenues get exhausted.
Answer
I am going through the same thing with me, what was the outcome of your question that may help me out. Thank you
What is the name of your state? Ohio
thank you for your time.
my name is francis. i'm 30, male. in late october 2005 i bought health insurance from assurant health/meidcal mutual of ohio. i had a back problem in october, and went to the neurologist in early november. i submitted the visit to my new insurance, fully expecting it to get denied because i had back pain previous to the visit. i just figured it would buy me time to get the money together for the visit itself. it didn't really matter, because by the time i went to see the neurologist my back was feeling fine, so i wasn't really worried about it.
however, a little less than a week later, something else happened. i noticed one night my left ankle was swollen very huge, and the veins were popping out of my leg. i went to the ER, and got a bunk diagnosis. a month later i had a follow-up visit and the doctor ordered an ultrasound of my legs. turns out i had extensive DVTs. i was admitted immediately, and they discovered i had a pulmonary embolism as well.
currently i'm just fine. i'm on the mend. with some extensive scanning and blood work they found i had a genetic blood disorder that makes me clot more than a normal person. they also found i have some birth defects in my venous system that may have contributed to the clotting. all in all, i should be fine, but i will probably be a lifer on anti-coagulation therapy, and may have the occasional hospital admission due to high or low blood "thin-ness"
now, i was really pleased by the fortune of having bought insurance before any of this happened. and all of my docs assurerd me that the idea that any of this being pre-existing is insane. the clots on the ultrasound and the CT scan were diagnosed as "acute" which means at MOST they were a couple of weeks old, clearly putting them within the time frame of me having bought insurance.
however my insurance company told me that since i didn't own any insurance previously (i don't know what that has to do with it. i had just got a decent job and thought i should be responsible about my care), and since i had this neurologist visit, that if they found even the tiniest evidence that i had even a sore muscle before my contract (which isn't hard since i was a professional athlete) they could call my clotting pre-existing.
what can i do at this point? do they have a carte blanche to deny me on such dubious pretexts as a "sore muscle"? my clots were diagnosed as acute, NEW clots. what can i do to prepare myself for a fight, and to force them to honor the policy? all my docs think it's crazy to call it a pre-exist, but it seems likely they're going to. what is my move to get ready in case they do? also, i just got laid off, so i can't afford an attorney. what then?
thank you so much. peace.
Answer
I am going through the same thing with me, what was the outcome of your question that may help me out. Thank you
well, there is no outcome yet. they're still investigating. and if i have to appeal, it might be a long process. however, the problem sort of lives in this area (as the gentleman up there said:
"i[f] the covered participant had symptoms prior to the effective date that would have prompted a reasonable person to seek medical attention, the later claims can still be denied as pre-ex. Each carrier words their contract differently, but most have some wiggle room concerning pre-ex."
the trouble here is what is a pre-existing symptom, especially for something, like i said, with symptoms as diffuse as DTVs? for example, rarely does it happen, but it can happen that when people have a clot in their inferior vena cava, they might have lower back pain? now, even though i had a specific athletic event that injured my back, they might try and call my lower back pain a sign of my IVC occluding. that would be lame, though, since the CT scans show my clots as acute - new - as of december 2nd. but i'm sure they'll use it. or, what about the fever i reported to my doc in mid october? early signs of clotting? they might try that too. truth of the matter is, with my clotting disorder, even my history of migranes might have been some kind of clotting. it wasn't - that's nearly impossible. but they might try that. i'm ready for them to try anything.
as for me, all i know is that they did an ultrasound of my legs, and BAM! - i was admitted with a pulmonary embolism. i never had any clue or warning, and i'm a pretty "reasonable person" so i'm ready for a fight. that "wiggle room" seems like "let's-find-a-way-to-not-support-our-client" room to me.
Answer
You are going to have to ride this out and see what happens.
From a carriers point of view, you had no insurance, you had symptoms, you bought insurance, problem solved.
On the surface it looks like you were out to cheat the carrier into paying for some expensive treatment. Not saying that was the intent, but it could be interpreted that way.
The carrier has every right to protect themselves and conduct a thorough investigation. If they deny your claims you have an appeal process.
On the other hand, one also has to ask this. If you did not have the insurance when the ankle problem manifested, would you have avoided a medical consult?
I doubt it.
So you are no worse off now than you would have been without the insurance. If the carrier can generate a medical trail from your back pain to the leg (DVT) and stay within the confines of the contract and deny they claim they will.
The scans may indeed prove the clots were new, but was the pain in the back a precursor to the eventual leg problems? Maybe, maybe not.
Answer
On the other hand, one also has to ask this. If you did not have the insurance when the ankle problem manifested, would you have avoided a medical consult?
well, the answer to this is obviously of course not. that was the first symptom of a DVT, absolutely. and that was well within the timeframe of having purchased insurance. but regardless, the whole ordeal was highly life-threatening, so you're right. i would have gotten in checked out. the problem is this part:
If the carrier can generate a medical trail from your back pain to the leg (DVT)
can they? i think even if they can't defensibly do so, they'll try. they said as much. from all of my doctor's opinions, they can't. the back pain was clearly the result of a stress injury from carrying a bike up a cliff, and the fever from an intestinal bug i had in october. the DVTs were sudden. that is a medical fact. and my doctors, the ones who provided me care in a clinical environment and had a chance to perform differential diagnoses at the time of my symptomology say as much.
unfortunately it is also a medical fact that STATISTICALLY, in some cases, certain symptoms i had are rarely associated with certain types of clotting. but, certain symptoms my girlfriend has had are associated with clotting as well - like calf cramps. but she doesn't have a coagulopathy nor a DVT. i'll bet you that any given person has had signs of DVTs before. it just seems like a really easy diagnosis to get out of for a carrier.
i just feel like they're going to manipulate certain medical stats to avoid a pay out. do they have a right to investigate? totally. but do they also have the ABILITY to protect their bottom line based on statistical opinions, and not the clinical activity that took place among my specialists... they sure do.
i've heard of things as bad as a man with kidney cancer getting denied because 2 years previous he had symptoms of back pain. that seems like crock to me.
From a carriers point of view, you had no insurance, you had symptoms, you bought insurance, problem solved.
On the surface it looks like you were out to cheat the carrier into paying for some expensive treatment. Not saying that was the intent, but it could be interpreted that way.
but symptoms of what? can they really say it was symptoms of a DVT? i think the burden of proof is on the company to demonstrate unequivocally that i had symptoms that manifested before i signed on. if they cannot directly make a clain against the two radiologists who declared my clots NEW, then they don't have a case. it seems to me unless they can dismantle that piece of evidence - that piece which clearly puts the development of clots at minimum three weeks after i bought the policy - then they have nothing. no matter what else they come up with, that piece of evidence still remains credible. my clotting was NEW, according to all standard clinical practice, and confirmed. AND that record of acute clotting is supported by at least 5 other specialists from other areas who have their own pieces to add to this as sudden-onset disease. no chronic clotting was found. only new. again, it seems to me, that no matter what else coud be conjecturally attributed to clotting, that element stands up firm and solid. unless they can take it down, they'll have to honor the policy.
back pain certainly can't have been a prior to clots. the pain would have happened when the clot formed. the inferior vena cava can't just say "hey, i feel a clot coming in a month. just thought i'd let you know now."
from a patient's point of view, i think they might just have to bone up and say "well, it seems like we were unlucky in this case." i'm sure they've said that to plenty of patients, and i'm prepared to ride it out until they do, for sure. i don't blame them for investigating. but i will blame them if they come up with weak dribble, which i wouldn't put past any company.
if i'm a bit edgy, it's because they basically told me on the phone "if we even find so much as a sore leg in the past 5 years, we'll deny." that is total garbage, don't we think? especially with the records of the doctors? how many of us on this forums have had cramps, or muscle strains? did we all have DVTs? i was a pro athlete. of course i have an orthopaedic history. i made that clear to them when i bought. does that now all become evidence for clotting? if it does, they're in for a fight, for sure.
for the record, somarco, i really appreciate your dialogue. it's giving me a lot to consider. so if i sound agrue-tastic don't take it personally. it's all just me working things out and bouncing against your input. have a good day.
Answer
They haven't denied anything yet right? I think you need to relax. Let them do their investigation, they're just trying to protect their interests, this is what helps keep your premiums from being higher then they have to be. It seems to me that it would not be medically reasonable for them to consider the DVT pre-existing. So just let them figure that out and chill out in the meantime. If they come out against you, THEN worry.
Answer
They haven't denied anything yet right? I think you need to relax. Let them do their investigation, they're just trying to protect their interests, this is what helps keep your premiums from being higher then they have to be. It seems to me that it would not be medically reasonable for them to consider the DVT pre-existing. So just let them figure that out and chill out in the meantime. If they come out against you, THEN worry.
that's incredibly sound advice. i suppose i am a little to amp-ed up about it. i'm just feeling a little bit at their mercy in a way i'm not too comfortable with. thanks for the input. you're probably right. we'll see what happens.
in the mean time, is this a good time to start talking to an attorney friend? i know the windows on appeals can be pretty tight, and i'd like to have me things in order. should i be getting ready in other ways? or should i just let it go altogether?
Answer
IMO, the only thing you should do right now is read through your policy booklet carefully and familiarize yourself with what the appeals process entails.
Answer
IMO, the only thing you should do right now is read through your policy booklet carefully and familiarize yourself with what the appeals process entails.
sound like a reasonable enough plan. chill, read, and wait. thanks a bunch, everybody with input. we'll see how it goes, and i hope it's okay to post again with updates.
thanks.