Is heavy bleeding a pre-existing condition?

HI,

I've posted on here before and my ob/gyn is going to schedule me for an ablation due to fibroids and heavy bleeding.

I am self-employed and self-insured, did not have coverage for 10 years before January.

I just had a call today from my orthopedic surgeon's office that my ganglion cyst on my wrist claim was denied because it's considered a pre-existing condition. I can understand this, because the cyst was very obvious and clearly I had it for some time. Also, the office manager told me that I should be aware that my particular insurance company rejects about 10% of claims using the pre-existing condition clause now.

So this has me worried about all the gyn testing and the ablation. The insurance company's pre-existing condition clause states that it must not have been diagnosed previously, which it was not. However, they also state that it must not be a condition that any prudent person would have sought help for before.

My question is: would heavy bleeding fall under the second part of the pre-existing condition clause?
I have to see the urologist today and I have basically the same question for the stress incontinence I will be evaluated for.

Have any of you had similar problems and how did you deal with them?

I think that the heavy bleeding should not be considered pre existing! I hope you get some answers today! Hugs Raymo

Hi Voo,

The statement 'must not be a condition that any prudent person would have sought help for before' seems to be a very subjective clause and would seem to be difficult to enforce. Unfortunately, a lot of these cases will be initially declined by the insurance administrator and the insured will have to appeal, sometimes several times, to get the decision overturned. Do you know if your plan is considered to be a fully insured plan? These plans are subject to state guidelines and your state might have different guidelines for what most companies would consider to be pre-existing. Addtionally, many plans have a time frame included in the guidelines. For example, a plan might have a 3/6 This would mean that any condition, that was diagnosed or first experienced within the 3 months prior to the start of coverage, would be subject to pre-existing. Therefore, there would be no coverage for this condition for the first 6 months of coverage.

Please appeal all of your denials...you have nothing to lose by trying and you might be very happy with the results. Good luck and I hope for the best outcome for you.

Well, I tried to schedule the surgery and already heard from the office manager that the insurance company is trying to claim all this is "pre-existing."
I'm going to fight it because it had never been diagnosed in the past, and I really thought it was normal and just the way I was, possibly because I was getting older.
If worse comes to worse, I will have to wait a year to get the procedures done. I just hate the idea that I've had to go through so many tests and so much agonizing over what to do, only to find out they won't let me do anything right now.

If anyone has any advice over fighting the insurance company over this clause, please let me know.
BTW, I had no prior insurance for 10 years, so the portability act does not apply to me.

Hi Voo. I would file a complaint through the state insurance commission. These complaints get taken more seriously by the insurance company as they will have to either overturn their decision or they will have to provide clear documentation to uphold their denial. If they can't adequately uphold their denial, they may be subject to penalties through the state.