OT: Insurance Company Trying to Claim "Pre-Existing Condition"

[Chris Robinson]

I need a few opinions on this.

During the last week of August, my back started to hurt so I went to the chiropractor for an adjustment. I got some relief. Two days later, he had wanted to see me again but this time my back was spasming before I went it. My feet were tingling and numb since I picked up my 6 year old son earlier in the day. The doc took a look at me and ordered an MRI the next morning.

The MRI revealed an 80% herniated disc between L3 and L4. I was referred to a surgeon who fixed me up on 9/1.

Now BCBS is saying that they're not going to pay for the surgery (although they initially approved it) by saying it was a pre-existing condition. They've asked for all the doctors names (including chiropractors) I've seen in the last ten years.

I have seen a chiropractor regularly (every few months) for an adjustment over the last five years. This year I only went a few times. Then the herniation in late August.

Any advice on how to handle this with BCBS? I really don't want to fork out the $20K it cost for this surgery.

Chris

[Duke Spinner]

Ouch ...!! ... $20k

isn't that why you paid for Health Insurance ..??

[Daddy Dee]

Chris,

My friend, I'm sorry to hear about your back and this experience with BCBS. Your health is enough to be concerned with when you've got a back injury like this and facing surgery. That's alot on it's own.

In my observation, there are frequent situations when insurance companies are programmed to say "no" before they say "yes". Whatever the BCBS appeals process is, get into it and keep all of your correspondence and documentation of conversations. It would also be helpful to have your employer's HR folks perspective and support through the process.

Hopefully BCBS will satisfy itself with it's investigation and do the right thing without much delay. If their appeals process ends unsatisfactorily, there is still the option of civil proceedings. That option is still a ways off.

Keep hanging in there.

[mark1101]

Sounds unusual. Most doctors get the procedure preapproved before they operate, and/or notify you beforehand of a no coverage situation.

[Chris Robinson]

Thanks, guys.

It was approved beforehand by BCBS They even authorized me for an overnight stay but I was feeling well enough after the morning surgery to go home that afternoon.

I think the glitch was when they realized I had chiropractic care before the surgery. I think they want the records to prove that my back was "waiting to happen" for the last three years. Never once did any of my doctors tell me that my back was herniated to any degree. When it went, though, it did a good job.

I'm a self-employed small business owner so my wife is my HR person [] She's concerned too. If insurance doesn't cover something like this,what do they cover? I was playing golf comfortably and well just a week before it blew out.

Chris

[DrWho]

We had this same problem for three of the last four surgeries I had...and they each cost quite a bit more than $20k [] I was young at the time, but I remember my dad's side of those phone calls. Things only got worse until he dropped the name of the "Better Business Bereau." Insurance companies hate dealing with them so after the first surgery got figured out it was easy getting them to pay for the rest.

If you are confident that it's not an existing case and they already approved the operation, then do not provide the names of the previous 10 years of doctors, nor do any of the crazy stuff they come up with next. If anything, have your current doctor write a letter to the insurance company stating that it's not a pre-existing condition and even have him detail the nature of the injury that caused it. Though even this isn't required because it's the insurance company's responsibility to do this at the beginning of your coverage (like before they approve you for their plan and determine your rates). And be firm on the phone and don't take all the crap they dish out. They're going to try and make you jump through a bunch of hoops - none of which you need to do (but you might want to check your insurance contract). I can pretty much guarantee that they are going to start sending bills to your home and eventually the hospital will too. Always tell the hospital that you have insurance and the operation was already approved - do not write anyone a single penny for anything. The hospital will come back saying it wasn't approved by the insurance and then you call the insurance company about the bill form the hospital (this is when you mention the BBB). If nothing happens, then actually call the BBB and detail your situation. The only time to start getting worried is when you get a warning note from a collection agency - and that's when you should find a lawyer.

We got as far as the collection agency twice, but both times the BBB was able to take care of it before we got lawyers involved. The first time they freaked out when we mentioned the BBB and the second time they actually had to deal with them. Basically you need to realize they're trying to use scare tactics - I swear a lot of this crap is illegal and if it's not it should be. [6]

Since I'm by no means a legal expert take all this with a grain of salt...I'm sure things are slightly different in every state and certainly with every insurance policy.

But I feel for you...dealing with insurance companies is not fun.

So how's your back doing?

[Daddy Dee]

I think they want the records to prove that my back was "waiting to happen" for the last three years. Never once did any of my doctors tell me that my back was herniated to any degree. When it went, though, it did a good job.

I'm a self-employed small business owner so my wife is my HR person She's concerned too. If insurance doesn't cover something like this,what do they cover? I was playing golf comfortably and well just a week before it blew out.

In my understanding of "preexisting condition" it is documented treatment that determines if the condition is "preexisting". I don't think the industry standard views it as your responsibility to prove that it wasn't there. Basically, if you weren't diagnosed, it wasn't pre-existing.

Knowing the date of your injury is helpful. The idea that you could have played golf comfortably with such an injury is absurd.

I think Mark's take is right.

[cmdridq]

Was BCBS picking up any of the tab from your chiropractor? If so, it would seem they knew about the condition and didn't have any issues then, so why now?

[PhilMays]

Someone posted earlier that sometimes it is proceedure to turn someone down. I have heard this before in disability cases. I would certainly go through the appeals process.

It may be cheaper for them to pay this off rather than deal with litigation and end up paying it off anyway. If this was nothing to this level in the past, I feel you can make an excellent case.

Insurance companies and Lawyers...that's what we need more of (not talking about you DWI Lawyer[])

[Duke Spinner]

(not talking about you DWI Lawyer[])

Aaaaahh ..

what about our friend, Def Jeff ..???

surely the taint is about him too ....[]

[MrMcGoo]

Chris,

If the herniated disk does not show on any prior exam (physical, X-ray etc.), BCBS is liable. Get a written statement from your chiropractor as to what changed and when it changed. Give BCBS the written waiver for your medical records. (Let them pay for the search.)

If BCBS persists, write the insurance commissioner's office in your state. Give the commissioner all of the FACTS.

Still no joy, hire an attorney and sue for the tort of "bad faith" which is insurance company fraud essentially. The insurance company can be held liable for punitive damages unless there is a valid reason for their change in position. Bad faith claims may result in BCBS being required to pay your attorney's fees in addition to the damages, both compensatory and punitive.

Bill

PS: If the insurance was provided by your employer, punitive damages are probably out due to TEFRA, the Tax Equity and Fiscal Responsibility Act of 1982. B

[arfandbark]

Chris,

Your BC/BS policy will have a paragraph or two regarding "pre-existing" conditions and how long the pre-ex clause will apply for...

Then look back to see when you first enrolled in the health plan.

If you received treatment for a back condition before your pre-ex clause expires you will have to work with your physician to prove to BC/BS that this is a NEW condition and unrelated to your prior treatment for back pain.

Sounds to me that your chiropractic care was more "maintenance" orientated than what you may see for someone who is receiving treatment for a chronic condition (x-rays every six months, bi-weekly visits, etc).

Insurance companies hate paying for Chiro care, by the way....

I assume that "pre-approved" for the surgery means pre-certified (some insurance companies phrase it differantly) and what that usually means is that your insurance plan won't penalize you for not calling them prior to the surgical proceedure.

At best the pre-certification process is handled by an RN and I don't think they look into pre-ex. At least they didn't use to.

The fact that BC/BS is requesting information from your health care providers leads me to believe that they haven't denied you benefits as of yet, but that they are trying to verify that the herniated disc is a NEW condition and unrelated to your prior chiropractic care.

In my opinion, that is what you need to prove to them...... Have your surgeon write them a letter or respond to the BC/BS letter stating it is a new condition (lifting 6yr old).

If the surgeon was referred by the chiropractor then that person is involved also and they will need something from him/her stating that prior chiro care was unrelated to the herniated disc.

As long as "herniated disc" doesn't appear in any of the diagnoses prior to your enrollment date I think they are obligated to pay your claim(s).

I'd wait until BC/BS rejects payment for benefits before you consult a lawyer or the BBB.

Get in contact with that chiropractor and explain what's going on. Make sure he/she understands what you need. NO PRIOR TREATMENT for herniated disc until after your enrollment date.

Get the providers of care to follow this lead and BC/BS has no leg to stand on and must pay your claim(s) for the herniated disc.

No, I didn't spend last night at a Holiday Inn.

I processed health insurance claims for about ten years a while back...

Arf

[Chris Robinson]

Thanks, all ... really good reference points here.

I feel a little less lonely as I hit the phones in the morning.

You all are great friends. Really.

Chris

[synthfreek]

Blue Cross/Blue Shield did the same thing with me. 5 or 6 years ago I had to be rushed to the hospital with kidney stones and they refused payment because the same thing happened about 5 years before that. I just never paid the bill. It was $5000 to be shot up with morphine all day and let the stone pass on its own. BS!