Pre-Existing Clause (Insurance Question)

Considering a Natale ablation.... His office emailed me about my insurance...

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*This policy does have a Pre-Existing Clause. If they decide to open a case for review, they will go back 3 yrs. on your medical history and decide if this was pre-existing and ineligible for benefits.*

I got my latest insurance in December 2019. And, I was diagnosed earlier in the year with afib. Does this mean I was pre-existing and that I'll have to pay for an ablation out of pocket/self pay???? If so that would really stink! Did anyone else here have to do a self-pay with a Natalie ablation?



Edited 2 time(s). Last edit at 02/11/2020 11:19AM by cirenepurzalot.

I didn’t have insurance once when having a tumor removed behind my ear. My HMO surgeon I was assigned (head chief of ENT) told me he was only given 45 minutes of operating room reservation so he would have no time to avoid cutting my facial nerves and I would wake up with a drooping eye and mouth. Plus he was flying 22 hours back from Egypt that day (jet lag) and would be coming straight to the hospital from the airport to operate. Plus due to lack of time he would cut my face across the cheek and because I was in my 40s “who cares how I would look afterwards?”

So I investigated a doctor at cedar Sinai who told me he would isolate my facial nerves and cut from hairline from eye to under neck (facelift crease) so I wouldn’t be maimed afterwards or have severed nerves.

I made a cash price at cedars that was affordable with payments for the hospital stay, operating room and all costs. Same deal with surgeon.

Ask around for a cash price and payments.

We'd have to see how the pre-existing clause is worded. I've never heard of anyone being denied over a pre-existing conditions clause. All you can do is let them submit for approval and find out what the insurance company says.

Thanks Carey. I haven't dealt much with insurance, but, if they get approved before the ablation is there any way that after the ablation they will come back and say it's not covered because it was pre-existing? Or once they approve it there's no reneging?

Once they approve it and you do the procedure, they have to cover it.

Ok that's good to know! I didn't realize that.

Carey, in regards to this....

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If they decide to open a case for review, they will go back 3 yrs. on your medical history and decide if this was pre-existing and ineligible for benefits.*

.... would they decide to open a case before approval? Or can they do it afterwards? Sounds like they can only do it before, according to what you said. I just dont know if I fall under pre-existing or not, as they define.



Edited 1 time(s). Last edit at 02/11/2020 03:58PM by cirenepurzalot.

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cirenepurzalot
Carey, in regards to this.




.... would they decide to open a case before approval? Or can they do it afterwards? Sounds like they can only do it before, according to what you said. I just dont know if I fall under pre-existing or not, as they define.

Here is my 2 cents worth. I would talk to my insurance company and make sure I am covered. I never rely on anyone to determine a answer for something of this magnitude except the people who actually have the final say.
Just be wise and call your insurance company

Thanks for your suggestion!

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cirenepurzalot
.... would they decide to open a case before approval? Or can they do it afterwards? Sounds like they can only do it before, according to what you said. I just dont know if I fall under pre-existing or not, as they define.

If they're talking about what I think they're talking about, it's the other way around. A review happens when the insurance company denies it. If Natale then challenges that denial, a conference between an insurance company doctor and Natale will happen.

Knowing nothing about your coverage or what the pre-existing conditions clause refers to, it's hard to interpret so take this with a grain of salt.

Under the Affordable Care Act, I thought pre-existing condition clauses were no longer legal.

Maybe this is a grandfathered plan?

See link below:
Pre-existing conditions

No, a short term plan, I paid for it in full for a year. I think these don't have to cover pre-existing conditions.

I think Allofus is right. Can you name the plan? I'd like to have a look at it online.

National General (Network by Aetna)
Aetna open choice ppo
Claims sent to Meritain Health

Thanks!!

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cirenepurzalot
National General (Network by Aetna)
Aetna open choice ppo

Okay, it's Aetna. No, you don't have a problem. I thought maybe you bought some ultra-cheap coverage from some dodgy company. But you didn't buy this policy before 2010, right? If you did, it's possible you actually do have pre-existing conditions exclusions. Otherwise, you can't and don't.

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Under the Affordable Care Act, health insurance companies can’t refuse to cover you or charge you more just because you have a “pre-existing condition” — that is, a health problem you had before the date that new health coverage starts. They also can’t charge women more than men.

https://www.hhs.gov/answers/affordable-care-act/can-i-get-coverage-if-i-have-a-pre-existing-condition/index.html

We just bought it in December. I sure hope we are good. We will call to confirm exactly. Thanks so much!!! Praying!

Carey, thanks for the info! We purchased this in December. On their website I do see this.... Website link here....

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SHORT TERM MEDICAL (STM) AND HEALTH CARE REFORM
THIS COVERAGE IS NOT REQUIRED TO COMPLY WITH FEDERAL MARKET REQUIREMENTS FOR HEALTH INSURANCE, PRINCIPALLY THOSE CONTAINED IN THE AFFORDABLE CARE ACT. BE SURE TO CHECK YOUR POLICY CAREFULLY TO MAKE SURE YOU ARE AWARE OF ANY EXCLUSIONS OR LIMITATIONS REGARDING COVERAGE OF PRE-EXISTING CONDITIONS OR HEALTH BENEFITS (SUCH AS HOSPITALIZATION, EMERGENCY SERVICES, MATERNITY CARE, PREVENTIVE CARE, PRESCRIPTION DRUGS, AND MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES). IF THIS COVERAGE EXPIRES OR YOU LOSE ELIGIBILITY FOR THIS COVERAGE, YOU MIGHT HAVE TO WAIT UNTIL AN OPEN ENROLLMENT PERIOD TO GET OTHER HEALTH INSURANCE COVERAGE.

THIS POLICY DOES NOT MEET THE DEFINITION OF QUALIFYING PREVIOUS COVERAGE OR QUALIFYING EXISTING COVERAGE. AS A RESULT, IF PURCHASED IN LIEU OF A CONVERSION POLICY OR OTHER GROUP COVERAGE, YOU MAY HAVE TO MEET A PRE-EXISTING CONDITION REQUIREMENT WHEN RENEWING OR PURCHASING OTHER COVERAGE.

This is from their coverage book....



I'll call to make sure, but I think this isn't looking good.... If only I had known before.....



Edited 3 time(s). Last edit at 02/12/2020 04:32AM by cirenepurzalot.

I didn't even know policies like that were available. It seems to be a stopgap sort of policy you would buy to cover a short gap in coverage, like for a month or a few weeks or so, not a policy you would rely on for continued coverage. Looks to me like you're out of luck until you can buy a real policy.

Yeah I think so. I'm looking into if I can purchase another second policy that doesn't care about pre-existing conditions.

Just call your Insurance Company. Surely by now you understand that it’s YOUR obligation to know if you are covered or not. You will have nobody to blame except Self if you are not covered. Please find out what you need to know straight from the horse’s mouth. When it’s all said and done, YOU will be the responsible party.
Have a great night and God Bless.

Yes, great advice!

Every time I see someone struggling with health decisions because of their insurance it infuriates me. I had the same issue this past year due to a new company taking over the operations of our plant. I never paid much of anything out of pocket and my scripts were very reasonable. But when the new company took over one of my scripts shot up to $400 a month and I had to find all new doctors.

I was able to switch insurance and go onto my wife's policy but there is no reason under the sun that anybody in America should have to worry about what doctor they are going to go to or what prescriptions they can or cant afford.

I hear ya. I wasn’t able to take the anti arrhythmic that was prescribed due to the high price. Insurance is so expensive as well.