Question:
Being declined for pre existing condition
I was insured on 4/1/04 by BCBS. My husband got great insurance and we picked his up through Principal on 6/1/04. Husband got laid off and lost insurance as on 9/30/04 but I picked up ins again through BCBS on 10/1/04. I have had 6 months of continuous coverage, but they are declining me based on pre existing condition. The only medical care I received regarding any obesity WLS related things has been in 6/04 to present. Before 4/04 I didnt see a doctor since 6/03. Principal approved me for surgery as medically necessary but we lost coverage too fast to schedule surgery. Talk about winning the lotto but collecting too late. BCBS is telling me I have to wait until 4/05 to be covered. They are also telling me that my plan most likely wont cover WLS as of 2005. What should I do? Doesnt HIPPA prohibit this? — BUTTERFLYMACKEY (posted on October 26, 2004)
October 25, 2004
Before 4/04 did you have coverage with someone else? BCBS will 'bridge'
time if you had other insurance. If not they can impose a pre-x clause -
up to one year . It doesnt matter wither you saw a doctor or not its
whether or not the 'condition' could have been around.
— star .
October 26, 2004
Boy, what a bad break . i feel bad for you but there is always a chance it
will be covered next year. Don't give up hope just yet. Also, HIPPA has
nothing to do with this. It concerns privacy issues.
— Delores S.
October 26, 2004
Actually, HIPAA does apply, but it won't get you exactly what you need.
HIPAA requires the insurance companies to bridge all of your coverage,
which they have done. It's just that the total time covered isn't enough
to eliminate the pre-existing condition limitation. Find out what BCBS's
definition of "pre-existing condition" is. If it says that it is
a condition for which you have sought or recieved treatment in the past 12
months, then you may be able to argue with them that your obesity does not
meet that definition as you have not sought medical advice in the past 12
months about this condition. However, if you take any medications for any
co-morbs, they can use that as proof of medical treatment. What you might
do is consider keeping your husband's previous insurance under COBRA just
to get the surgery paid for. You should still be within the time limit to
elect that, but I'm not sure how your now being re-covered by BCBS will
affect your eligibility there. It's worth looking into, but fast before
the clock runs on that.
— Vespa R.
October 26, 2004
Yes, it is the HIPAA law that covers this issue. See this
site..<br><br>http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html<br><br>From
what I remember you must be covered for 18 months with no more than a 60day
break in coverage in order for the pre-existing not to apply. They may be
denying you because they do not have proof of your coverage during the
break. Your husbands insurance company should have mailed you a
portability paper once your coverage was terminated. If not, request one.
The thing is, you will need to show proof of coverage prior to 4/04 as
well. Best of luck. Becky
— RebeccaP
October 26, 2004
Rebecca,
Unfortuntley this happened to me. I also had BC/BS and had just picked up
coverage in February 2003. I went to a weight loss seminar and the program
submitted my imfo but BC/BS denied coverage because of the pre-existing
condition. They said I had to have 18 months credible coverage from a
previous insurance with no more of a 6 month lap in coverage. I had'nt had
insurance since August of 2002. So there for they put a 1 year pre-existing
on my covereage and said I had to wait one year. SO I waited my one year
and in March of this year I resubmitted all my stuff for WLS and guess what
they said I had needed 1 year of pysician diet monitored diet within the
past 2 years. Well how in the he** was I suppose to get that if they
wouldnt pay for any weight loss treatment. If I would have known that ahead
of time i would have visited my doctor many times for diet control and make
sure the weighed every time I visited and was monitring my diet thru the
year. Luckly I picked up insurance thru my job I started in March and
United HealthCare paid for my surgery. Good luck. They can be real
sticklers. Take care. Jen:)
— imgabbie
October 26, 2004
Ooooh Jennifer....they have to give all of the reasons for denial the first
time! BX can't do that! I am glad you did finally get things worked out
though. :D
— RebeccaP
Click Here to Return