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Landon C | Is this a pre-existing condition?? |
My insurance started on Jan. 1st 2008 ... I went to the ER on 12 11 2007 for a 7mm kidney stone and they referred me to a urologist who has been really doing nothing but giving me pain pills until the day my insurance started so i can get the surgery ... see my work gave me time off from 12-11-2007 until the 1st of Jan. when my insurance kicked in so i can get the surgery ... so since i have seen this doctor before, will my Atnea insurance cover this ... I have not been on any insurance since around May of 2007 ... i called atnea and they said they go back 6 months whatever that means ... and when i call the insurance they do not want to give me a yes or no answer whether or not it is going to be covered ... i have been paying for all the office visits out of pocket. Am I going to have to pay for the surgery out of pocket as well please help me |
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sarah314
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Yes, it is a pre-existing condition.
"Looking back 6 months" means that anything you've been treated for/diagnosed with/taken medication for in the 6 months before your policy started will be pre-existing.
Your ER visit was less than a month before your insurance started. (Thus within the 6 month lookback period.) Therefore, its pre-existing.
If you'd had continuous insurance coverage (without a gap of more than 63 days), then you'd get credit for your prior coverage and you'd have coverage for services related to the pre-existing condition.
However, this does not apply to you, because you had a break in coverage from May 2007 through January 2008.
There's not much you can do about that, unfortunately - pre-existing clauses are pretty cut and dry. Either you were treated/diagnosed within the past 6 months or you weren't. Either you had continuous prior insurance coverage or you didn't. No grey areas there.
(This is why I always encourage people to not go longer than 63 days without insurance coverage...you never know if a medical condition is going to pop up and you'll be stuck.) |
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dragon lady
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Ultimately, it's up to the insurance company to decide. I know what it's like, though, to try to get a straight answer on what should be a simple question. How many times have you called when they won't give you a straight answer? Every time you call, write down the name and i.d./badge number of the person you talk to. If they won't give you an answer, ask to speak to a supervisor. I've had situations where I've called to find out something, and I spent hours on the phone getting passed along. The key is to be persistent. You should also find out if your doctor's office has a patients advocate who might be able to help you. Usually they know how to talk to the insurance people and actually find out information. |
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mbrcatz
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Yes, it's pre-existing. Yes, you're going to end up paying for this out of pocket. Because of that, shop around to a few different local hospitals, and get the pricing IN ADVANCE. |
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jontbundy
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Unfortunately, I believe it is a pre-existing condition.
Your illness was a condition that existed before you had valid health insurance. If your health insurance says it goes back 6 months, it means that for the past 6 months, any illnesses you had don't qualify for insurance payment.
Sorry. :( |
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hightechchic
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It will definitely be considered a pre-existing condition (the pre-existing part isn't determined by whether or not you received the surgery, but by the fact that you were diagnosed with the problem.)
In SOME (though not many) cases, employers pay extra on their group plans to have pre-existing conditions covered for newly added employees. It does not sound like this was the case in your situation; however, you may want to contact someone in human resources at your employer and ask. (The fact that Aetna didn't indicate this was the case does not necessarily mean it isn't the case.)
However, barring this special circumstance, there's no other way around the pre-existing condition issue. Still, there may be one advantage even if this is the case -- you should ask Aetna if their network providers will honor the network discounts for you since you're now a member, even if it's going to be treated as a pre-existing condition. Many companies negotiate that into their network agreements and it may mean the difference between having to come up with $2,000 and having to come up with $17,000. (No, I'm not exagerating. Actually, I'm probably estimating low based on the figures I've seen.)
If Aetna responds that the network providers should still honor the network discounts, request documentation in writing and document every detail about the conversation (including who provided you with the info, when, their contact info, etc.) This could be very valuable later! |
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Candace C
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I am sorry for you. Health care in the US is a b***h. I very much doubt if they will cover you.
However, you may be able to access their discounted arrangements with providers. if it is urgent to have the surgery, then you have to do it for you health. If Aetna has awareness of the preexisting deal, like if it is in any record they have or can get , it is most likely to be denied. The bills should still go to them and you can possibly get discounts, if this is a PPO plan.
I'd research the heck out of your health care options, insurance options, discount plans and other types of treatment possible. See if some friends can help you. Aetna will not be very helpful, in all likelihood, so do your own research. |
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