Pre-Existing Conditions

Insurance… it is constantly changing.

Here are some of the changes and what they might mean to you:

Insurance changes affect everyone. Over the past year the changes have occurred at a dizzying pace. Many insurance companies are now offering cheaper policies; however, this often means less benefits for the patient. The fact that you have a policy does not automatically assure you of coverage the next time you visit your doctor. You must take the time to understand the benefits of the policy and how the benefits (or lack thereof) affect you.

Most of the issues discussed here apply to OFFICE VISITS with a physician or specialist. Hospital coverage is another issue entirely. Always consult your policy documents for verification of the benefits that apply to you.

Pre-Existing Conditions

Many policies tack on a pre-existing condition clause. This is a waiting period during which any illness or disease that occurred before the insurance policy was effective may not be covered. If this clause applies, you may be responsible for the entire cost of treatment.

In order for your insurance company to categorize you as having a pre-existing condition, you must fulfill the following requirements:

1. You must be over 18 years old. The newly passed health care reform laws do not allow minors to be assessed with pre-existing condition clauses.

2. You must have a lapse in coverage of 60 days or more. When you discontinue coverage with an insurance company, that company provides you with a Letter of Credible Coverage. This letter proves to your new insurance company that you were covered until the date stated in the letter. If you can provide your new insurance company with this letter, that may cause them to have the pre-existing condition clause removed from your policy. Do not assume that because your previous coverage was with the same company, they know you were covered. You must notify the insurance company in order to have the clause removed. It is in your best interest to take care of this as soon as you acquire new insurance. If you did not have a lapse in coverage, then pre-existing condition cannot be assessed.

3. You must have a condition that pre-dated the coverage with the current insurance company. This condition must have been treated by a physician and recorded in your medical records. The insurance company will send for medical records from all previous health care providers in order to verify whether this condition existed before you were covered. If you were never treated for the current condition, it is not a pre-existing condition and should not be assessed by the new insurance company. This does not mean that they will pay your claim immediately. Your claim may be delayed by their investigation into the pre-existing condition issue. However, if no treatment of the condition exists, they should eventually pay the claim.

If any one of the above items does not apply, you have escaped the pre-existing condition clause.