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Are Colon Polyps a Pre-Existing Condition?

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Old 04-13-2009, 04:46 PM   #1
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smachias HB User
Question Are Colon Polyps a Pre-Existing Condition?

Hello All-

My mother lost her job and has COBRA insurance, she recently had a colonoscopy where a polyp was found that could not be removed during the procedure. The polyp is currently benign but she has to have a colorectal resection to have it removed. In 2005 she also had a colonoscopy where a polyp was removed. No one will give us a straight answer as to whether or not the surgery will be covered by her insurance (I guess because she had a polyp before?). I've been reading up on insurance, but I'm really confused. Is there a list somewhere out there that shows what is considered a pre-existing condition? Has anyone else been through this?

Thanks for your time.

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Old 04-13-2009, 10:49 PM   #2
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Re: Are Colon Polyps a Pre-Existing Condition?

Usually each policy has a clear definition of what "pre-existing" means in that policy. See if there's a glossary or definitions page.

Often pre-ex refers to any related condition or treatment that occurred within a certain time frame before the policy coverage began.

-For example, it could say no condition is covered if it is pre-ex, if it occurs within the first 12 months the person is covered. As an example, if the colonoscopy was 9/1/08. The insurance coverage began 10/1/08 and the poilcy excludes pre-ex from 12 months prior to coverage - then if there is any claim for anything related before 9/2/09 it can be considered pre-ex and may not be covered.

-But if the colonoscopy was 5/1/08, the insurance started 6/1/08 and the pre-ex period is one year AND the surgery is needed 7/1/09 - then it's likely not pre-ex.

A colonoscopy that found a polyp would be "pre-ex" if the person is seeking any treatment or medication or consultation (etc) for colon issues.

The key will be (1) the policy's specific definition of pre-ex (2) the period they look at (i.e. 12 months before coverage began, or 3 mo, or 60 days, etc).

Policies do vary widely.

Once you've had coverage for a while, nothing is then pre-ex under MOST policies. So, for example, if the polyp was found in 2005 and she has been covered since 2006 and now needs colon treatment of any kind - it's likely pre-ex does not apply.

I hope that wasn't too much of a rambling answer.
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Last edited by SpineAZ; 04-13-2009 at 10:50 PM.

Old 04-14-2009, 10:38 AM   #3
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smachias HB User
Re: Are Colon Polyps a Pre-Existing Condition?

Thanks SpineAZ. My mother has only had insurance (there was over a 63 day lapse) since December. The surgery really needs to happen so that the polyp doesn't become cancerous. I guess we may just need to find out what finance options are available in case the insurance won't help.

Old 04-15-2009, 04:51 AM   #4
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Ethez HB User
Re: Are Colon Polyps a Pre-Existing Condition?

I don't know if this is help but I just had a colonoscopy and they removed the one polyp they found and called it "pre-cancerous" and as I understand it they said all is good and not to worry. As far as insurance goes I thought polyp removal was a part of the colonoscopy. I have to look closely at the bill when it comes. There is no reason why your insurance company cannot tell you what you need to know. Stay on the phone until you get an answer and document dates and times you interacted with them. When the bill comes and they stick you, then go back to your times and dates and raise the roof on them to get the charges dropped. I'll go over my bill and get back to you.

Old 05-12-2009, 10:27 PM   #5
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Re: Are Colon Polyps a Pre-Existing Condition?


Would be interested to hear how your colonoscopy was handled by your insurance co. I have a high deductible policy ($3000) with an HSA. My deductible does not apply (i.e., the insurance company pays the cost of) to certain "preventative" procedures and visits; colonoscopy is mentioned specifically.

I had two benign polyps removed and one was biopsied. I was shocked when I received the EOB from my insurance co. I was sure that the deductible would not apply. The explanation from the rep: The procedure was "preventative until the doc clipped the polyp and then it became therapeutic." Even tho the doc submitted a code that said it was colon cancer screening, the clinic's bill was coded for the "surgical" aspect of it and so the insurance co. would not accept the docs code for the procedure. Doc + clinic + anesthesiologist = $4700.

The purpose of reimbursing for preventative care is to encourage people to seek care that will prevent illness later on. Like colon cancer maybe! And of course who could argue against the removal of the polyps as being preventative. I am appealing--it is ludicrous on its face and i feel pretty sure I will win

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