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Health Insurance.  Deny claims due to pre-existing conditions?

Sometimes it seems we can't win with our current healthcare system in the United States.   We shop around for the best health insurance rates, find premiums we can live with-- and for a time we feel safe and secure.  We're covered.  Then... some have had the unenviable experience of paying hundreds of dollars per month for their health insurance, filing a claim and having it promptly denied.  What's up with that?

Insurers need to protect themselves.  This is true.  Fraud is a real problem.  Pre-existing condition clauses exist in order to prevent a new potential policyholder from jumping aboard with a health insurer simply to get a known condition treated and paid for at the unsuspecting company's expense. 

So first... here's a quick explanation of what a health insurer might consider a pre-existing condition:
Pre-existing health conditions include any illness, injury or other condition for which medical advice, diagnosis, care or treatment was received or recommended during the six months prior to your health insurance plan effective date. Benefits for these conditions are usually available after you’ve been covered by your new plan for 12 consecutive months.

Let's look at an example of how the pre-existing condition clause would come into play with an individual health insurance plan.  A health insurance company would deny claims due to pre-existing conditions if, in the 6 months preceding your current claim, you were treated for a given condition.  For example...  You visit a doctor in April for pain in your back.  Let's say you're with Humana at the time.  Your treatment is paid for by Humana and you're sent on your way by the doctor who prescribed some pain killers for what he thought were muscle spasms.  In July, you decide to change carriers.  In August, the pain in your back returns-- and so do you-- to your doctor.  He performs more tests and informs you that you have a herniated disc that will require surgery.  Yikes.  Your claim is submitted to the health insurance company and denied due to the pre-existing condition clause.

Once the health insurer looks at your doctor's records, they'll know that you've been there before for a similar problem.  At the time-- perhaps the doctor didn't diagnose it properly-- but it's not hard to uncover the reality.  This is a problem that has been with you.  The only way you could have hoped to be covered for this condition is to have gone until the following April for treatment.  This would have met the 12 month requirement. 

With group coverage-- your outcome could've been different.  If you have continuous coverage under a group plan, when you change employers (and consequently group health plans), your claim can't be denied for pre-existing conditions.

As with all insurance, we always advise you to ask lots of questions when running premium comparisons.  It's not all about the premiums after all...  You often get what you pay for.  Although it's not always true, lower cost can mean inferior coverage.

So after you run quotes by entering your state of residence and clicking "Health Insurance Quotes"... be prepared to ask your agent or broker:

-- What is the pre-existing condition clause of the company being proposed?
-- What is the company rating?
-- Is your current physician participating with the carrier?
-- What are the deductible options?
-- What are the co-insurance requirements?
-- What is the doctor visit co-pay?
-- How does the prescription drug coverage work?

Good luck in your quest for affordable health insurance you can rely on...