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Old 04-28-2010, 08:30 PM   #1
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Had a 6 months lapse in coverage and now needing surgery, ? regarding pre-existing

I had insurance with my employer for a year and then I had 6 months that I was not with them. I returned with them in January. In February I decided to go to the doctor because I was having lots of pain in my foot. This is the same foot that 20 years ago I had surgery to repair a torn tendom. The last time I went to a doctor on my foot was in 1997. The only time period that the insurance is looking at is from July 2009 thru December 2009. They are looking at everything and sending letters to every doctor that I have ever seen or am currently seeing. I am proceeding with my surgery because my doctor feels that it is necessary and to honest it really hurts and I can not continue to suffer with the pain without doing something about it. I would however like to know that it will be fully covered like my insurance policy says. We have great coverage with the exception of the pre-existing clause.

 
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Old 04-28-2010, 10:27 PM   #2
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Re: Had a 6 months lapse in coverage and now needing surgery, ? regarding pre-existin

You'll want to check out the exact wording of the pre-existing exclusion/limitation in your health insurance plan. Every plan is different in it's definition of pre-existing, the period they will look back, etc. Often the wording is such that the plan will not cover any condition for which you sought treatment in a specified period before coverage began.

Here's the basic information:

*If you were on your employer's health insurance plan, left and took COBRA for the 6 months, then returned to your employer -> then you are not subject to pre-existing exclusion/limitation as you had continuous "group health coverage" with no gap of over 63 days.

*If you were on your employer's health insurance plan, left and did not elect COBRA and had no other group coverage (i.e. through a parent, spouse, partner, etc) for 6 months -> then you are subject to the pre-existing exclusion/limitation due to gap in health insurance coverage of more than 63 days.

As an example:
*You are hired by XYZ Company on 2/10/1998
*In 1998 XYZ Co. health insurance coverage begins 1st of the month following date of hire
*Thus health insurance coverage began 3/1/98
*You resign / are laid off / are fired 4/30/09
*XYZ Co. health insurance plan says coverage ends on last date of employment
*Thus health insurance coverage ends 4/30/09
*You do not elect COBRA and have no other health coverage.
*You are rehired by XYZ company on 10/2/09
*XYZ Co. health insurance begins 1st of the month following date of hire
*Your INSURANCE EFFECTIVE DATE is 11/01/09

AND:
*You have bunion surgery 05/15/10.
*Pre-ex is 12/12 (if you go out in first 12 mo of coverage the insurance company looks back for the 12 month period immediately prior to most recent INS EFF DATE
*INS EFF DATE was 11/1/09, ins. co. looks back 12 months prior to 11/1/09 to see if there is any treatment, consultation, medication, complaint etc for bunions. This includes any statement in medical records that says "Jane Doe came in today for examination, prominent left bunion, discussed bunionectomy and medications. Jane Doe asked for medications and was given a prescription for Naproxen"
*If they find anything in that period, then coverage for the condition is denied
*If there is nothing in that period, and nothing is found, coverage is allowed.

From what you stated in your post you have not had any treatment, medication, consultation, examination, etc for this foot problem. In that case you will likely be covered for the treatment.

The hard part is that the insurance company has to do an exhaustive search to make sure there isn't anything in that period.

Pre-ex will likely not be an issue in the future under the new federal guidelines that get phased in over time.

Be very forthcoming with the insurance company. Give them the name of everyone you've seen and every pharmacy you've used. Offer to sign any release form needed, etc.

Let me know if this helps or if I can clarify further
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