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Author Topic: help insurance question????  (Read 828 times)

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Offline l29

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help insurance question????
« on: September 04, 2008, 11:06:56 PM »
Hi,  I really don't know much about insurance and am hoping someone on here might.  I  seen my os for a check up of my left knee during a period before I got insurance.  Now I have insurance and had hurt my right knee and had an mri of both knee's in which the doctor said he would put down it was a new injury. now the insurance is refusing to pay saying it is a pre existing condition.  The left is some what understandable but not the right knee as I have never had anything done on that one.  How do these clauses work, is it the whole knee that is excluded? as we all know you have many parts in your knee ligaments tendons cartilage etc.. and when they exclude one do they exclude the other knee as well?

Offline FormerlyActive

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Re: help insurance question????
« Reply #1 on: September 05, 2008, 04:58:51 AM »
It depends so much on which country you live in, which state and which insurance you have. For example short or long term, and which carrier, which type of plan. You should start by reading your policy carefully. It also depends for how long prior you were un-insured. Also it depends if it was an individual policy or a group policy.
Depending on the situation, besides the health questions you may have had to answer they may also have asked you to sign a release of records which would include probably at least a few years worth.
Sorry can't be more help. First step would be to have a careful read of your policy, and if you went through an agent you might want to talk with the agent prior to contacting the insurance company.
3/82 - Medial Synovial Plica removal both knees
9/89 - Lateral Release both knees
3/08 - Reinjury left knee hiking Asia Pac
5/08 - Miserable Malalignment diagnosis
4/08 - 9/08 Five doctors diff. opinions
7/08 - 02/09 - In PT, no chg.
4/09 - Dr. 6 opinion femur & tibia derotation together

Offline over it

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Re: help insurance question????
« Reply #2 on: September 05, 2008, 01:00:11 PM »
I agree with the above comment but after you have researched your policy and still feel that the claim should have been paid for, you can contact you state's insurance commission and file a claim with them to investigate your allegation.  It doesn't cost you anything.  In the state of Colorado, they have a web site you can file your claim on.  Good luck! 

Offline jathib

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Re: help insurance question????
« Reply #3 on: September 05, 2008, 06:01:03 PM »
The pre-existing condition does not include your other knee if you've never had anything done with it. Insurance companies go out of their way to deny claims so it's up to you to appeal. Your doctor should be helping you with this. Often it's just a matter of knowing what wording to use. My insurance has no pre-existing condition policy so I've never had to deal with it personally.

A new injury is a new injury and depending on the diagnosis for the previous injury it may or may not be defined as pre-existing. Again, your doctor needs to help you with all of this.

Offline clemmy

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Re: help insurance question????
« Reply #4 on: September 05, 2008, 07:11:27 PM »

Your policy should include a section on appealing a denial. Take a look at that section to determine what you can do to appeal the denial for your right leg. You stated "now I have insurance and had hurt my right knee."  The challenge will be to prove that the injury occurred after you got insurance. Generally you have to exhaust all appeals available through your insurance company before you complain to a state insurance entity.

If you applied for a private policy you were probably required to fill out a questionnaire and go through underwriting to obtain the policy. Often policies include exclusionary language for a period of time for conditions that you disclosed during the underwriting process. If you make it through underwriting, insurance companies often scrutanize claims that occur shortly after. Basically they are on the look out for people who only get medical insurance because they think they might have something wrong, that doesn't mean that you sought treatment prior to obtaining insurnace. If something shows up very soon after obtaining a policy, it sets off red flags. It doesn't matter that you never had that knee treated, what matters is whether the injury or symptoms occurred before or after the policy date. And if before the policy date, whether a reasonable person would have sought medical care for it. In other words, if you purchased the policy knowing you had an untreated injury to your right knee, but had not sought treatment for it, the insurance company can exclude it.

If it is group policy that you purchased through your employer, you should look for your states insurance comission website to see what the laws are, as they vary state to state.