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Author Topic: Insurance company claiming "pre-exsiting condition"  (Read 3905 times)

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Offline Threepaw

  • Member
  • Posts: 10
Insurance company claiming "pre-exsiting condition"
« on: October 03, 2011, 10:45:02 PM »
Currently in a bit of a fight with my insurance company (Coventry health care of Louisiana), I have the insurance through my workplace and a few days ago I received a letter stating I needed to resubmit all my claims from my ID doctor, because they feel that my diagnoses is one of a pre-exsiting condition.

I'm not too savy with how insurance issues like this should work, I was diagnosed less than 2 months ago, and have been on the insurance for almost a year, I suppose one could argue that I acquired HIV prior to that point, but both my primary doctor and my ID doctor have called this a Acute infection, going so far as to state in my medical records that the infection probably occured around mid to late May.

I guess I'm just concerned that they will continue to deny my claims and in that case, what exactly can I do?

Thanks for the time,
If I wake in the morning I only need two more miracles to be a saint.
March 2011 - May 2011: exposed
8/18/11: Dx HIV-1 B
8/25/11: CD4 111 13% VL 894346
9/13/11: CD4 66   11% VL 709245
9/16/11: Started Atripla
10/14/11: CD4 265 15% VL 1638
11/23/11: CD4 329 13% VL 100

Offline Miss Philicia

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  • celebrity poster, faker & poser
Re: Insurance company claiming "pre-exsiting condition"
« Reply #1 on: October 03, 2011, 11:51:59 PM »
You should read this entry, specifically the "Definitions" section and then follow the link in the statehealthfacts for the line on Louisiana.


Basically as I read it that state uses the "prudent person" definition, so they see a pre-existing condition if they can somehow prove you, as the patient, were exhibiting symptoms and ignoring them I guess during some window of period previous to your diagnosis. As far as what window period "look back" I guess 12 months applied.

I think one of your old posts indicates you live in New Orleans. I would really sit down with an AIDS Service Organization case manager before you send this insurer any further documentation, especially if you doctor thinks this is unusual. How does the doctor go about proving that it's a recent infection I guess would be the best bet.
"Iíve slept with enough men to know that Iím not gay"

Offline Gary S

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Re: Insurance company claiming "pre-exsiting condition"
« Reply #2 on: October 04, 2011, 03:40:31 PM »
Were you on a group insurance plan prior the one you are on now without more than a 60 day lapse before starting up with your current plan. If so, I believe under federal law you would be exempt from any preexisting condition clause  with your current company (should they think they have a leg to stand on)  because you would have satisfied it with your previous insurer

Offline phildinftlaudy

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  • sweet Ann what you think babe...
Re: Insurance company claiming "pre-exsiting condition"
« Reply #3 on: October 04, 2011, 04:17:55 PM »
I also believe that a "pre-existing" condition is one that either diagnosis and/or treatment has been received for prior to coverage date (or other specified date/condition).  So, even if you have a condition 5 years ago - if it was not diagnosed (that is the operative word) than they can't deny your claim - of course, they would have to be able to show that it was diagnosed previously.  Otherwise, if you go strictly off of the what the word preexisting connotates - dayummmm near everyone and every condition could fall under the category as some people have conditions that may have existed since birth, but were not "diagnosed" until they they got much older (take for example congenital heart disease, diabetes, etc).

September 13, 2008 - diagnosed +
Date    CD4    %   VL     Date  CD4  %   VL
10/08  636    35  510   9/09 473  38 2900  12/4/09 Atripla
12/09  540    30    60   
12/10  740    41  <48   
8/11    667    36  <20  
03/12  1,041  42  <20
05/12  1,241  47  <20
08/12   780    37  <20
11/12   549    35  <20
02/12  1,102  42  <20
11/12   549    35  <20

Offline Threepaw

  • Member
  • Posts: 10
Re: Insurance company claiming "pre-exsiting condition"
« Reply #4 on: October 04, 2011, 05:35:03 PM »
Yeah that's what I was thinking, if they keep trying to claim Pre-existing after my resubmitting the claim then I'm going to fight tooth and nail, though today I got a letter telling me that I'll have to start filling my Atripla through their "specialty" pharmacy or they won't cover it  ::)  just one thing after another it seems.
If I wake in the morning I only need two more miracles to be a saint.
March 2011 - May 2011: exposed
8/18/11: Dx HIV-1 B
8/25/11: CD4 111 13% VL 894346
9/13/11: CD4 66   11% VL 709245
9/16/11: Started Atripla
10/14/11: CD4 265 15% VL 1638
11/23/11: CD4 329 13% VL 100


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