by FLTeacher » Thu Mar 12, 2009 02:29 pm
I live in Florida and was accepted into BlueCross options in September. However, coverage did not go into effect until December as there was a mix-up when our company's paperwork was sent in (Bluecross lost it). I have a 1 year pre-existing clause. My question is: I went into the ER in October and was diagnosed with gallbladder disease, gallstones, infection and thickening of the gall bladder walls. I also had to go back in December for basically the same symptoms. I have been advised that BlueCross will not cover as they consider it to be pre-existing. I am currently having severe attacks and was told by a nurse (on my last ER visit) that if they have to perform emergency surgery to take out the gallbladder, my insurance may have to cover it. Is there any truth to this? Any help would be greatly appreciated!!
Posted: Thu Mar 12, 2009 02:43 pm Post Subject:
My first thought would be to contact your HR department and get proof that you submitted the paperwork (whether it be confirmation of a fax or even just a letter from someone). Contact BlueCross and explain that you made every prudent effort to be enrolled in the program in September, and that you should have been covered prior to December. If you had previous insurance coverage, there may be a way to get out of the 1 year pre-existing clause.
What the nurse was probably referring to, and keep in mind that the clauses vary from company to company, is the following example. If you had multiple problems with a kidney, and they were pre-existing conditions the company may not pay for a kidney transplant. However, if you are involved in some type of accident and the weak kidney is injured...they would pay for a kidney transplant due to the mechanism of injury (the nature of the complaint). A lot of it depends on the ICD9 (medical terminology codes used for insurance billing, etc.) codes and how they code it.
Unless anybody else has any other suggestions, I would start with HR and see what you can prove and then contact BlueCross. It may help to emphasize to them that you are not interested in having them pay for your medical bills in October-December...but that you do need them to understand the predicament that their error has caused you to be in.
Posted: Fri Mar 13, 2009 09:31 am Post Subject:
I'd hope that since the fault was on part of Blue Cross , they would be considerate at covering your surgery.
Chris is right, get things clarified from the HR.
Posted: Sun Mar 15, 2009 06:59 am Post Subject:
First, stop getting your insurance information from a nurse, doctor or any medical professional. They do not know your policy. That said, I have some questions. Is this coverage through your employer? Others mentioned that you contact human resources, but you never mentioned that this was employer provided coverage. If it is through your employer do they have a waiting period for coverage to kick in? Is this the first time you were diagnosed with gallbladder disease? Did you make copies of the original paperwork sent in September? Prior to September, did you have other health coverage through another insurance company, or did you have a break in coverage?
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