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Pre-existing conditions and healthcare insurance claim

Pre-existing conditions and healthcare insurance claim

Old Apr 4th 2009, 4:52 am
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Default Pre-existing conditions and healthcare insurance claim

Just before we had to leave the States and move to Canada (the company my husband worked for closed the US branch) he had treatment for an ear infection for which he claimed health insurance (covered by the company). It was two visits to an ENT specialist, so about $1500 (+$80 prescription payments up front). He has an underlying ear problem, for which he has been treated on and off since he was a small child, but not in the last few years. The doctor filled in a form for the insurers and said it was a pre-existing condition, so they refused to pay up and we have been sent the bill (now in red demands as my husband didn't really want to think about it, but still gave the doctor our Canadian address).

I have had a look at the policy and it says:
Pre-existing Conditions
􏰀 Month-for-month credit will be given to enrollees who had Medicaid coverage and/or other prior continuous creditable coverage provided there is no lapse in coverage of more than 63 days.

􏰀 GHI and GHI HMO will provide credit toward pre-existing condition limitations for prior creditable coverage under foreign plans to the same extent and according to the same standards that apply to domestic plans.

So, am I right in assuming that NHS coverage should count as a foreign equivalent to Medicaid, and what does month-for-month credit mean? We only had the insurance for about three months, they had a different company before that, and we came straight to the States with no break in coverage.

What proof does the company want? I can give them the details of my husband's previous doctor in the UK, who will have the medical records, but we found in the past getting them to send anything to us was tricky.

Any help would be welcome - I'm damned if I'm going to pay out $1500 (esp as from Canada it will be nearer to $2k!)
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Old Apr 4th 2009, 2:18 pm
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Default Re: Pre-existing conditions and healthcare insurance claim

You basically need to prove to the current company that you had continuous coverage. If you were covered long enough under the previous insurance provider, then you do not need to worry about getting any kind of proof of coverage from the NHS. Not knowing what state you are in, in my opinion, if you were covered under the prior insurance provider for at least 12 months, you should be good to go to get any pre-existing condition covered under the new policy. But you need to confirm that the current provider only has a 12mo prior coverage clause to cover a PEC. It could be as long as 18 or 24 months prior coverage.

You need to get a statement from the prior provider showing the dates he was covered. Hopefully the time period he was covered is long enough to meet whatever clause the current provider has about covering pre-existing conditions. It's usually standard operating procedure to send this doc when a policy is terminated, so you may already have it.

Last edited by Bluegrass Lass; Apr 4th 2009 at 2:22 pm.
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Old Apr 4th 2009, 4:45 pm
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Default Re: Pre-existing conditions and healthcare insurance claim

Ah, previous US provider was for maybe a month or two at the most - the company was in the process of changing it's coverage when my husband arrived in the States.
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Old Apr 4th 2009, 9:28 pm
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Default Re: Pre-existing conditions and healthcare insurance claim

Originally Posted by nooka View Post
Ah, previous US provider was for maybe a month or two at the most - the company was in the process of changing it's coverage when my husband arrived in the States.
And prior to that time, you were in the UK? Several other ex-pats on here have stated that they have gotten statements from the UK doctors stating that he was covered by the NHS, which is essentially health insurance, from birth.

Ahh..here is information from another post:

Here's some - this is apparently the HIPAA "final rules":

http://www.cms.hhs.gov/HealthInsRefo...IPAA-05-01.pdf

"For example, coverage through Britain’s national health care program, or through the U.S. Veterans Administration, neither of which previously satisfied the definition of public health plan under the interim final group market regulation, must be considered creditable coverage for that purpose."

From Blue Cross, re. legislative update:

http://www.bcbsil.com/PDF/legislative_update_405.pdf

Text won't copy for me, see paragraph beginning at bottom left of page 2, continuing onto top of next column.

Willis Legal & Research Group:

http://www.willis.com/Documents/Publ.../BAIssue30.pdf

'The final rules also add two new categories of health coverage that now qualify as HIPAA creditable health coverage for individuals seeking to reduce or eliminate any preexisting condition limitation period under a new health plan. Coverage provided under a state children’s health insurance plan (SCHIP) or coverage received under a foreign national health plan (such as may be found in Canada or Great Britain) now constitutes creditable coverage. Unfortunately, the rules tend to dismiss the obvious administrative headaches facing an employer who must try to ascertain whether coverage existed in a foreign national health plan. However, the regulations acknowledge that an employer may request documentation showing that the individual actually established legal residency in the foreign country before the employer must recognize that coverage as “creditable.” '

The last sounds as if you simply need to prove residency.
If you get a statement from the doctor about being covered by NHS, and prove he was living/residing in UK from x to y dates (whatever length of time the insurance provider requires in order to cover a PEC) you may be able to swing this in your favor. Good luck.
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Old Apr 5th 2009, 4:23 am
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Default Re: Pre-existing conditions and healthcare insurance claim

Thanks - that looks very useful
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Old Apr 5th 2009, 12:01 pm
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Default Re: Pre-existing conditions and healthcare insurance claim

Originally Posted by nooka View Post
Just before we had to leave the States and move to Canada (the company my husband worked for closed the US branch) he had treatment for an ear infection for which he claimed health insurance (covered by the company). It was two visits to an ENT specialist, so about $1500 (+$80 prescription payments up front). He has an underlying ear problem, for which he has been treated on and off since he was a small child, but not in the last few years. The doctor filled in a form for the insurers and said it was a pre-existing condition, so they refused to pay up and we have been sent the bill (now in red demands as my husband didn't really want to think about it, but still gave the doctor our Canadian address).
Also, ISTR there being something in group plans about pre-existing conditions being defined as conditions for which you have received treatment in the last X months/years. Sorry, can't remember the detail, but my point is that this may not be a pre-existing condition under the terms of your plan.
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Old Apr 5th 2009, 8:00 pm
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Default Re: Pre-existing conditions and healthcare insurance claim

Originally Posted by sunflwrgrl13 View Post
You basically need to prove to the current company that you had continuous coverage.
Actually thats not quite true. You have to show CREDITABLE coverage which not all insurance counts towards and you are allowed a gap of under 63 days. It's not a blanket thing, you accrue creditable days which can be used to reduce the pre-existing condition time. Each creditable day you are insured means 1 less pre-existing condition blackout day.
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