Insurance Exclusion

[Bryan B]

The big difference is if you are signing up for an employer provided group plan or trying to buy individual health insurance. For group plans provided by an employer there are federal laws (mainly HIPPA) that limit the time insurers can deny coverage for preexisting conditions (generally 6-18 months) regardless of what the preexisting condition is and how far back it goes. When it comes to individual policies it's usually up to the insurers (and state laws if applicable) as to how far they can look back and how long they can deny coverage for preexisting conditions.

I know that when I had a 12 month lapse of coverage and then got coverage through an employer they had a 12 month preexisting condition clause for my heart condition. That meant that I didn't have my annual cardio followup in 2007.

 

[hensylee]

is that called a "GOTCHA"? at least if you have appendicitis, you are covered. or a broken leg, or......... maybe that's a good thing, after all.

 

[james]

I guess this is what congress is talking about right now? Your situation is exactly why I have not gone out on my own and continue to work for a large corporation. Then again they have laid of 5000 people this year....
Good Luck.

 

[ChouDoufu]

i've already taken out my new health policy, i just got a response from another
expat insurance provider. they have a similar restriction on pre-existing
conditions, first a moratorium period with no coverage, then normal coverage
if certain conditions are met:

Please be aware, a two year Moratorium applies to all new members which
excludes treatment for pre-existing conditions. The definition of a
pre-existing condition is:

any known medical condition (or related condition), that has within a two
year period immediately prior to your start date, had one or more of the
following characteristics: -

a) been diagnosed
b) needed medical treatment (including drugs, special diets and injections)
c) for which medical advice has been asked for including check ups
d) for which medical advice should have asked for if recognised clinical
advice had been followed
e) has undiagnosed symptoms, whether investigated or not

After two years of continuous insurance cover, pre-existing medical
conditions will become eligible for benefit (unless the condition or the
benefit is specifically excluded under the plan wording in the membership
guide), if at the first time of receiving treatment the insured person has not:


i) suffered any symptoms
ii) Consulted any physician for check-ups, medical treatment or advice.
iii) Taken any medication (including drugs, special diets and injections)

for that medical condition or any related condition for a continuous period of
two years.


so this means you can have a pre-existing condition and get coverage
for it, as long as it's not pre-existing? i've got a condition, and i know
about it, and now you know about it, but i can't go to a clinic for a
simple blood test to see if i've still got it?

i especially like the part about the "special diet." i'm sorry, but we'll
have to deny you coverage. we've accessed your american express
records, and it seems you ordered the 'healthy heart' breakfast
slam at denny's four years ago.

 

[ChouDoufu]

so now i finally understand....i got no heart coverage, never ever.

i was confused as they added an exclusion in the same paragraph as
the moratorium period. why confused? because the moratorium period
in the standard policy is "For Pre-existing Cancer and Cardiac conditions,
the moratorium period is extended from 2 to 5 years however we do not
class routine check-ups as active treatment, therefore should you remain
all-clear after 5 years, you will have full cover."

but there was the exclusion "Exclude Cardiovascular system, treatment
thereof, causes and sequels" that seems to contradict that.

so the moratorium on pre-existing conditions does not affect me, as they
have excluded all my pre-existing conditions for the life of the policy.

 

[Lynlw]

i've already taken out my new health policy, i just got a response from another
expat insurance provider. they have a similar restriction on pre-existing
conditions, first a moratorium period with no coverage, then normal coverage
if certain conditions are met:

Please be aware, a two year Moratorium applies to all new members which
excludes treatment for pre-existing conditions. The definition of a
pre-existing condition is:

any known medical condition (or related condition), that has within a two
year period immediately prior to your start date, had one or more of the
following characteristics: -

a) been diagnosed
b) needed medical treatment (including drugs, special diets and injections)
c) for which medical advice has been asked for including check ups
d) for which medical advice should have asked for if recognised clinical
advice had been followed
e) has undiagnosed symptoms, whether investigated or not

After two years of continuous insurance cover, pre-existing medical
conditions will become eligible for benefit (unless the condition or the
benefit is specifically excluded under the plan wording in the membership
guide), if at the first time of receiving treatment the insured person has not:


i) suffered any symptoms
ii) Consulted any physician for check-ups, medical treatment or advice.
iii) Taken any medication (including drugs, special diets and injections)

for that medical condition or any related condition for a continuous period of
two years.


so this means you can have a pre-existing condition and get coverage
for it, as long as it's not pre-existing? i've got a condition, and i know
about it, and now you know about it, but i can't go to a clinic for a
simple blood test to see if i've still got it?

i especially like the part about the "special diet." i'm sorry, but we'll
have to deny you coverage. we've accessed your american express
records, and it seems you ordered the 'healthy heart' breakfast
slam at denny's four years ago.

THIS part is even better

"d) for which medical advice should have asked for if recognised clinical
advice had been followed
e) has undiagnosed symptoms, whether investigated or not "

So that means IF you had heart surgery and on NO meds but skipped your yearly check up just so you can have the pre existing condition covered, then you are still screwed because they will deny you saying well you SHOULD have gone to the doctor last year..

I really like the exclude for symptons you don't know about, I bet the can exclude paying for almost anything you MIGHT get with THAT clause

 

[Lynlw]

so now i finally understand....i got no heart coverage, never ever.

i was confused as they added an exclusion in the same paragraph as
the moratorium period. why confused? because the moratorium period
in the standard policy is "For Pre-existing Cancer and Cardiac conditions,
the moratorium period is extended from 2 to 5 years however we do not
class routine check-ups as active treatment, therefore should you remain
all-clear after 5 years, you will have full cover."

but there was the exclusion "Exclude Cardiovascular system, treatment
thereof, causes and sequels" that seems to contradict that.

so the moratorium on pre-existing conditions does not affect me, as they
have excluded all my pre-existing conditions for the life of the policy.

So it says you can have routine check up with your primary doc (not a specialist) as long as you do NOT mention your heart?
also Don't forget any problem that comes up that can possibley in the teenist way be related to your heart, that can fall under ..excluded, which pretty much covers anything that is not a trauma related.


When Justin was a baby insurance then (20 years ago) did not cover "well baby" visits, vaccines ect, ok that's sucks but is fine. Well they denied paying for his cardiology appts, they tried to say thos appt fell under the "well baby" exclusion. I had to argue for MONTHS to get them to see WELL BABIES did not go to cardiologist every few months, I understood the ped doc wasn't coverred but any specialist pretty much means it isn't a well baby. I swore if living in the hospital for months on end didn't drive me insane all the fights with the insurance company would.

Even his surgery he had at 17 they coverred, but almost 2 years later I got a letter, that they had questions about that claim and they were not responsible for surgeries cause by things like airplane crashes, dog bites... that we should have put a claim into the 3rd party that caused his problem and BSBC wanted reembursed. I pointed out IF they botherred to look at the history they already paid for several other heart surgery as well as testing and cardiolgy appts every 6 months for 20 years so should no he did not need this heart surgery because he fell out of an airplane or a dog bit him. and BTW we just found out he will be needing another heart surgery and that wasn't caused by being hit by a car, so please make a note of that on the computer.