Question
Ohio-
Began coverage with Amercian Republic Insurance, an Emerald Health Provider, and three days later saw a doctor about a strange vertigo and vibration in my head, as well as trouble breathing. The doctor ordered many tests, and directed me to a neurologist. The neurologist scheduled an MRI and EEG.
Neither doctor could find anything wrong. The total expenses came to $6,000.
The insurance company is denying my claims becaise I told my doctor that I had similar "vibrations" in my head about three years prior. And because the shortness of breath had began a week before my policy took effect.
Is this legal? Do I have a case to submit to court? The exact reason for the denial states that I had "pre existing symptoms for this condition". However, I have never had vertigo, nor a prolonged "vibration" or a shortness of breath. And on top of it all, I have never been diagnosed with a "condition".
any advice is appreciated.
Answer
This is not a legal matter. This is a contract matter. Whether they can deny your claim on this basis depends on the terms of the insurance policy, which no one here has read.
You have the right to appeal the decision. The method for doing so will also appear in the insurance policy.
Answer
To my knowledge, AR only writes individual coverage, not group. As such their underwriting practices are more stringent than would be so with an employer group plan.
As cbg has indicated, this is a contractual matter. The fact that you admitted to your doc that you had these symptoms prior to the effective date of your policy will make it much more difficult to prove this is not a pre-ex condition. This also dillutes your ability to effectively challenge the denial.
Appeal the claim but get your checkbook ready.
Answer
The contract reads:
Pre-Existing Condition Means:
(A) the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within a 6 month period before the date coverage begins for a covered person; or
(B) a health condition for which medical advice was given or treatment was recommended by or received from a doctor within a 6 month period before the effective date of the coverage of a covered person.
There is no question that I was having symptoms before coverage began. The point is, I never recieved treatment for those symptoms until after the policy took affect.
Do I have a case, or should I bend over and take it up the butt?
Answer
"To my knowledge, AR only writes individual coverage, not group. As such their underwriting practices are more stringent than would be so with an employer group plan."
Does this also mean that there is a conflict of interest?
In Pinto v. Reliance Standard Life Ins. Co., the court ruled in favor of the plaintiff stating that "In this case, the insurance company did have the discretion to interpret the terms of the policy. The company also operated under a conflict of interest because it both funded/administered the policy and determined the eligibility for benefits."
Answer
We don't KNOW if you have a case. We haven't seen your medical records, and we don't know if there is other language elsewhere in the policy that affects the part you have provided.
It's entirely up to you whether to appeal the decision or not.
Answer
Thanks. you have been VERY helpful.