Money Hungry Mayo, Violated Veterans

[Carolyn J]

Hello Zio 2224,
God Bless you and give you strength.
One of my own "Survival Sayings/Mantras" was very strong in my thoughts as I read your above "BPI Journey"...."When you reach the end of your rope, tie another knot and continue to hang on and hang in.

You are in my prayers~
Carolyn J
LOBPI/71++++

[minniem]

When I was in the car accident I got the "loop hole shuffle". Despite having full coverage on the car; health insurance; disability insurance; a disabilty clause on my life insurance; and a legal case against the car manufacturer and the car dealership I ended up paying for every medical bill. Mayo was just one of the bpi clinics who refused to see me because I had no way to pay for even the first visit in one lump sum. I never ever got to see a specialist... I have been stuck with a pre existing condition for ten years and will be the rest of my life aka I will forever have to pay cash for medical care.

I am glad you got the surgery you needed and I hope you see the recovery you are hoping for.

[katep]

I hate money-grubbing doctors and clinics, and people who act like their skills just dropped out of the sky and they owe the world nothing! So sorry both of you got that sort of treatment at Mayo. They should be ashamed of themselves.

minniem, as far as pre-existing conditions go, if you get group health insurance (covered by HIPPA) the "look-back" period is only 6 months, which means that only conditions where "medical advice, diagnosis, care, or treatment was recommended or received during the 6 months prior to your enrollment date in the plan". If your BPI still falls under that description, a HIPPA plan can only exclude treatment of the pre-existing condition for 12 months (or 18 months if you are a late enrollee). Many plans are less (my husband just started one which has only 6 months exclusion period).

I'm not positive but I think the new healthcare reform extends the same sort of pre-existing condition restrictions to private plans, too.

Kate

[karategirl1kyu]

wait, didnt this new health care reform bill thing call for the non descrimination when getting insurance?? aren't they not allowed to turn you away due to a "pre-existing condition"??

[katep]

Any health plan that is offered through employers and is under HIPPA (which is almost all employers) can have a maximum pre-existing condition exclusion period of 12 months (18 months if you don't enroll on the first opportunity but are a "late enrollee" instead). Pre-existing conditions are ONLY something that for which medical advice, diagnosis, care, or treatment was recommended or received during the 6 months prior to your enrollment date in a HIPPA plan. The example given on the Department of Labor HIPPA plan specifically mentions arthritis as an example:

"As an example, you may have had arthritis for many years before you came to your current job. If you did not have medical advice, diagnosis, care, or treatment - recommended or received - in the 6 months before you enrolled in the plan, then the prior condition cannot be subject to a preexisting condition exclusion. If you did receive medical advice, diagnosis, care, or treatment within the past 6 months, then the plan may impose a preexisting condition exclusion for that condition (arthritis)."

So even though you have BPI or some other long-term condition, if you have not sought or received treatment in the 6 months prior to enrolling on an employer-provided HIPPA plan, it still doesn't count as a pre-existing condition. My husband's shattered leg (and eventual need for a knee replacement) from our car accident in 2005 is not a pre-existing condition as he has not seen any doctor for it in over a year.

As for companies making up rules... expect it. It happens ALL THE TIME. People in the benefits office are NOT rewarded if they tell you the truth of what the plan covers. Expect it... but don't let them get away with it!!

When you get an insurance plan, request a copy of the Evidence of Coverage - EOC (they are required to give it to you). You can even get this before you sign up on a plan. Read it and read it again. This document is your friend!! Find out all the places where the insurance company itself spells out these things - what is a pre-existing condition, what is the exclusion period, what constitutes a "significant break" in covereage. It's all in there. And an insurance company's literature WILL BE COMPLIANT with HIPPA if it is a group health plan. It may or may not be compliant with state laws, if the plan is not based in your state. State laws, however, cannot "water down" the protections of HIPPA but can only improve them (allowing 120 days as the definition of a "significant break in coverage" for instance).

Once you have the EOC you can talk back to those really annoying benefits people when they try to feed you their line of bullshit and simply say, for example,

"But the definition of pre-existing condition you just told me conflicts with Section X, paragraph 5, part i which specifically says that pre-existing conditions are only those for which I received medical advice, diagnosis, care, or treatment was recommended or received during the 6 months prior to enrollment in your plan? Which, by the way, is consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). So I'm a little confused. Since we seem to be having a disagreement over interpretation of the law and the Evidence of Coverage, may I request that you consult with someone there and get back to me, in writing, with the actual determination in my case?"

That usually works

Kate

[Carolyn J]

A GREAT HELP post, Kate. Thank You for the very helpful Wording to use with the Insurance Co.
HUgs,
Carolyn J

[katep]

Thanks Carolyn.

Both BPI and adoption are cases that the insurance people don't come across all that often, and the agents often use "logic" (or what they consider to be their version) rather than really knowing the law and their own governing documents. Parents and those affected really have to be prepared to educate their insurance brokers, agents and HR people... possibly even against their wills

Unfortunately, there is NO incentive for anyone in insurance to be educated in this way. Instead, they actually benefit when they give people misinformation that leads those people to not utilize their insurance benefits to the fullest amount possible. So there currently exists an ANTI motivation for them to be properly educated and trained! I strongly believe that insurance companies should be able to be fined for giving out information that is contradictory to applicable laws or their own documents. THEN maybe they'd be motivated to train their people better!!!

Kate

[karategirl1kyu]

to be perfectly honest, i got insurance through Dunkin donuts, where i work. its good insurance, and they didnt ask me any questions about pre-existing conditions or anything... is that uncommon?

[karategirl1kyu]

i have moderate use of my left arm. i do what i need to do... i do most of my lifting with my unaffected arm