Question
What is the name of your state?What is the name of your state? Pennsylvania
I had a hernia for over a year (no insurance). I get a job that provides insurance after the standard 90 day wait. In my benefits book i read that they actually DO cover pre-existing conditions, as long as you have not been treated or diagnosed within the 3 months prior to being covered. Fantanstic!!! I wait my 90 days in which i dont get treated, get the insurance, and 2 months later my opperation. This was the end of October. 2 days ago I get an "explaination of benefits" in the mail stating the cost of my opperation( $27,082.02). It goes on to say that they will pay 0 and i will pay 27,082.82. Turns out another stipulation for getting a preexisting condition covered is being insured for 6 months. I will and almost have been covered for 6 months at this point. Had i known i had to wait 6 months I, of course would have waited!!! I had already waited over a year and my condition hadn't worsened. While a hernia is limiting it would not have been a problem to wait another 6 months. Am i at fault for misunderstanding my coverage. Is there anyway around this?? I understand why insurance companies have this policy. The problem is that I did not break their rule intentionally. I misread. I can't even fathum paying $27,000 because i misread. Should not I have been told that I would NOT be covered before the procedure. Ihad every intention of keeping my current insurance longer than 6 months. Please help!!!!
Answer
Misunderstanding your contract with your insurance will not help relieve you of the debt. It is unfortunately your responsibility. You can attempt to negotiate with the hospital and may be able to get a discount on the bill for payment in full. Or you may qualify for some financial assistance depending on financial status.
"Should not I have been told that I would NOT be covered before the procedure"
The hospital and Doctor probably received a preautorization from your insurance- although it is not a guarantee that it will be paid it is a guarantee that your policy covers the service- however, because of the preexisting clause it was denied. The doctor or hospital probably did not indicate to your carrier that it was a pre-existing condition ahead of time or they would have been advised it would not be covered. Ultimately it is your responsibility to know your benefits and know when you are under possible pre-existing exclusions.
You should have called your carrier ahead of time to make sure they were aware that it was preexisting and see that they would cover it and/or advised the doctor that you could have pre-exisiting limitations. They would have then checked with the insurance carrier at the time they obtained the authoriztion.
It is always best before going through with a major elective procedure to check what your financial responsibility will be.
Just in case you arent aware, the doctors bill seperate from the hospital. You will most likely be responsible for the doctor and anesthesiologist as well.
Answer
Should not I have been told that I would NOT be covered before the procedure.
By whom? Your doctor? Why should it be his responsibility to find out when you are covered?
Your insurance carrier? Why is it their responsibility to hold your hand through the policy and until your bills are submitted how do they know you intend to have the procedure anyway?
Your employer? Same responses as for the insurance carrier.
Why is it anyone's but your responsibility to know what you are covered for when? The answer is, it isn't. YOU are responsible for knowing what will be covered when, and if you don't understand it's your responsibility to ask. It's no one else's responsibility to decide that you need someone to explain your policy to you.
This is no one's fault but yours.
Answer
CBG,
Perhaps my response is inappropriate, but I cannot help myself. This is about the best answer I have yet to read on this forum.
Yes, I am all about educating folks when it appears they need it, but facts are facts and it is time someone pointed out that those facts are available to people. The fact that insurance plans and policies are boring is not an excuse. Try claiming ignorance of the law when a policeman arrests you! I've printed this so many times....READ YOUR PLAN DOCUMENTS FOLKS! EDUCATE YOURSELVES! Do not rely on ignorance of your plan or threats to the insurer! Insurance plans are contracts, not carte blanche for you to do as you want! lkc15507