Question:
If I self pay for surgery, my Insurance doesn't cover it. Will they pay for after care?
Or any other problems? This is what it says for pre existing conditions: the participant shall provide the plan with a certificate of creditable coverage for any pre existing condition for which the participant is seeking to obtain coverage under this plan. upon receipt of such a certificate, the plan shall subtract the creditable coverage from the 3 month waiting period for the reciept of services by the participant under this plan unless that employee has suffered a gap in creditable coverage(excluding the 60 day waiting period for this plan) of at least 63 days. No benefits are payable for pre existing conditions : Except: (01) after any three consecutive months during which the individual is covered and no medical care or treatment was rendered or recommended in connection with the condition:or (02) with respect to the participant only after any 6 consecutive months during which she was continuously covered hereunder:or (03) with respect to eligible dependant only, after any 12 consecutive months(including the 60 day eligibilty waiting period)during which the eligible dependant has been continuously covered hereunder. however, a pre existing condition of a dependant of a class D (commisionary) employee who is not enrolled in the plan within 31 days after the dependant first becomes eligible for the plan shall not be covered until the expiration of 18 consecutive months during which the eligible dependant has been continously covered hereunder. can someone help me understand this, and if I can use my insurance if I have any problems after self paying for the surgery? — Tawnee P. (posted on March 21, 2003)
March 21, 2003
I don't work for an insurance company, and although I'm a lawyer, I'm not
practicing anymore. Therefore...don't take what I'm about to say as
gospel. But it seems to me that a problem that arises post-surgery would
not be a pre-existing condition, assuming you have insurance. I'm assuming
you've had your insurance for awhile, and your insurance company has just
decided not to pay for surgery. If that is the case, then they will pay
for any problems (i.e., things that require hospitalization) post surgery.
I don't think they'll pay for follow up visits with your bariatric surgeon,
but again, I don't know for sure. This section that you've quoted here
relates to things the insurance company won't cover right after you've
started insurance with them -- i.e., if you had a different insurance
company, or no insurance, and some sort of health problem. I hope this
makes sense. Email me if you'd like and I'll try to help you.
— Tamara K.
March 22, 2003
I have seen people post similar things here before and I think usually the
insurance if they deny you for obesity surgery also will not pay for
anything connected with it.
— Delores S.
March 22, 2003
My insurer told me that they would not cover any complications that arise
from a denied procedure (or an unauthorized one) for 12 months following
said procedure. After that they don't investigate. During the 12 months
if they can trace your health problems to the procedure in any way, shape
or form it will be denied. Of course every insurer is different, but I'd
make really certain of it before hand. Good luck!
— [Deactivated Member]
March 22, 2003
<P ALIGN="left">At the risk of sounding like a broken
record, check directly with your insurance company and get a reply in
writing.</P>
<P ALIGN="left">Or, if you have your insurance through your
job, check with your human resources department. It's their job to explain
that insurance gibberish.</P>
— Kasey
March 22, 2003
The 2 most important factors are how long you've had this policy and if
you've had insurance coverage prior to this policy--and that includes
COBRA. What the policy is basically saying is that they won't cover a
condition that you had prior to obtaining this policy for any condition you
were seen for (minimum 60 days max 12 months for a dependent). That means
it also depends on whether you are the policy holder or a dependent. It
also basically waives the pre-existing clause if you were covered 6 months
prior to obtaining this coverage (usually you have to show proof of prior
coverage-this comes from you prior insurance-they'll send out a letter when
your coverage ends). If you didn't have a lapse of coverage more than 63
days before the coverage of this policy, then all you pretty much have to
do is show that you had another insurance plan before this one and weren't
seen for that problem 3 months before the beginning of this policy.
I know insurance mumbo jumbo can be confusing, but once you get it out of
the way you will understand and know how to deal with them better. I hope I
made sense the way I answered your question. Feel free to contact me if you
have any more questions @ [email protected]
Robin...finishing up pre-op testing
— Robin J.
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