pre-existing clause on health insurance policy

bec415 · 11-01-2006, 06:27 PM

Because I had no health insurance all of last year, I have a pre-existing clause on my policy. So every time I see a Dr, the claim needs to be processed/reviewed before the Dr. is payed. If they deny the claim, I have to pay for it.

They say a "pre-existing condition" is something you have recieved treatment for in the 6 months prior to joining the policy. Or, it was important enough that any reasonable person would have. I didn't see a Dr. at all until I started this policy, so there's no way they can call it pre-existing.

After waiting over 6 months for the "review" my claims have been denied. Every single Dr. visit has been denied. So I have to appeal now, and I'm not sure what to write to what I should send in.

Jashobeam · 11-01-2006, 06:34 PM

I'm sorry your claims were denied! I'm glad you are appealing. My Mom had to do that a lot because her insurance would make mistakes and deny things that they should have paid. I hope your appeals are approved!

avonlady1981 · 11-02-2006, 01:55 AM

i am wondering myself about that- i ahev had about half denied and half paid...and now i have to get nutrition counciling- don't know if they are going to pay or what...

bec415 · 11-02-2006, 06:10 PM

avonlady1981, do you also have a pre-existing clause? It goes for the first 12 months of the policy, so I'm thinking now I'll wait the 5 months until my full 12 months is up before I start any other form of health care.

I'm already on a payment plan with the hospital for a thyroid ultrasound and biopsy I had done which has been denied, so I've got to pay off over $1,000 for that alone. If I had know I would have waited a year for that too, I can't aford this and I don't want to get myself in any deeper.

nomadic_existence · 11-02-2006, 09:10 PM

Don't you love HMOs and health insurance plans these days??

I swear, they are all greedy companies who refuse to pay anything, and you end up footing the bill for stuff you can't afford. It pisses me off. My DH used to have really good insurance, but I guess his employer didn't like how much they were charging them, so they ended up putting us on BLUE CROSS which 1, cost too much, and 2, didn't cover ANYTHING. We ended up getting rid of it. We can't afford health insurance for ourselves, but we purchased a single plan for our daughter so she is covered. It's horrible that in this day, you can't get anything treated because the HMOs are so greedy.

I'm sorry you are going through this. What matters is health and health care is NOT a luxury. It's a necessity.

Editing to add: What is the point of paying for coverage that doesn't COVER you, KWIM?? It's ridiculous. I'm angry for you!!! You stil end up paying a buttload out of pocket.

guineapig · 11-02-2006, 11:07 PM

Yeah, pre-existing clauses can suck. Some things, like cancer, they can refuse to cover for years unless you had prior continuous coverage blah blah.

How do they know it was pre-existing, if you haven't had treatment for it in the past 6 mo to year? Did you list the condition on the application?

bec415 · 11-03-2006, 01:42 AM

I'm with Horizon blue cross. Unfortunately, that's the only insurance company with individual coverage in New Jersey and they're extremely expensive - but my employer pays for it. (that's why I have this job)

I hate Horizon! They're dishonest and wrong, no other way I can explain it. I didn't get any treatment for anything while I didn't have insurance so according to their deffinition of a pre- existing condition - I didn't have one! I am sending off an appeal letter, but it's out of my hands. They have the power to decide not to pay it .