Question:
Denied, Pre-existing Condition/Lapse in Insurance: Should I Appeal???

I have Blue Cross Blue Shield/Blue Choice since August & pay $156.00 a week. There was a three month waiting period, before my husband could apply for the insurance, in the first place (there can't be a lapse in coverage more then 63 days) we had a lapse of 180 days, counting the 90 days he had to wait to apply for the insurance. Before he got this job we couldn't afford health insurance, (in between jobs) without him working (I can't work/medical}. First of all you have to have a per-existing problem to even get this surgery, also the insurance company wouldn't let us get the insurance as soon as my husband started work. They said he signed papers stating this clause, there is nothing in the papers he signed. We've never had a lapse in insurance before this. They told me, I can have the surgery after one year. They told the Doctors office it was the pre-existing condition, plus they don't approve this operation. They DO approve this operation, it is in the coverage book. Has anyone had this problem and tried to appeal it??? If so what happened? I don't want to put myself though this unless there's a chance. It took over three months to even get the doctors office to turn in my paper work, then the insurance company to answer. They paid for my pre-op doctors visit, etc. They pay for my primal care doctor and also medicine I take (for pre-existing conditions). It doesn't make sense to me... What do you think??? [email protected]    — Nancie Z. (posted on January 20, 2003)

January 20, 2003
I am sorry to hear that you were denied. I too was denied by BC/BS PPO because I had a lapse in coverage. They also told me that they do cover the surgery, but only if you are covered a full 365 days before the surgery with them, or with no lapse in coverage. From what my surgeon tells me there is no way around this except to wait, that means I will have to wait until June of this year to submit my paperwork once again. Don't get discouraged, I know that you are feeling so upset right now, but know that you are not the only one who this is happened too. I am in the same boat. E-mail me if you have any questions.
   — Raine180

January 20, 2003
Keep in mind, a pre-existing condition is a specific condition in which you treated for (or saught medical help for) prior to electing coverage. In other words, since there was a lapse in coverage, if you were seen or treated for morbid obesity within 6 months (sometimes a year depending on how the coverage reads) of coverage, it is a pre-ex condition. If you were not seen within that time, then it is not a pre-ex condition even tho you had the condition. there really isnt any way around a pre-ex condition other than time. However, I question the fact that they paid the pre-op visit...it will still fall under pre-ex guidelines depending on which diagnosis they billed. There are some diagnosis that do not fall under the guidelines, for instance pregnancy or well visits. And some companies will "ignore" conditions such as common colds. It is your call to question the payment of the pre-op visit, however, if it was an error on their part, you may end up paying for it out of pocket. Good luck
   — roryleigh