Need some help figuring out some insurance problems..

Question

I know, I should call and ask, but it's the weekend and they are not open lol. I applied for the gastric bypass surgery and it got approved, but it says "Effective dates of approval" : From 7-28-08 to 1-28-09, but then bellow it it says "Pre-exist waiting period" : 4-5-08 to 4-5-09. I just got on my husbands insurance, we go thru wellmark, what could this mean? I'm sooo confused. Hopefully someone can help me!

Answer 1

I would like to recommend you grab as much as resource as you can before making decision,here is a good place for that purpose.http://insurance.free-onlinetip.info/ins...

Answer 2

Just because it has been determined a medically necessary procedure, doesn't mean that it will be covered because of the waiting period.

Of course you should confirm this with them.

Answer 3

You need to call and confirm, but it appears that they have approved the surgery to happen between July 28, 2008 and January 28, 2009, but your pre-existing condition period extends through April 5, 2009. That means, should you decide to have your procedure, it will not be covered, because you haven't met your pre-existing requirements.

Did you have previous coverage, and did you have less than a 63 day break between that coverage and your current coverage? If you did, you need to provide proof of that coverage to your new insurance, to get rid of that pre-existing period.

You need to call them and find out what happens if your procedure cannot be done prior to April 5, 2009. It will probably require additional pre-certification, but your provider should be able to show proof that you have to go through additional pre-procedure education (like a nutrition class), which will extend the time limit. I know it's frustrating, but that's a good thing.

You are stuck, however, at trying to show that this procedure should not be considered pre-existing, if you didn't have previous coverage. This is an ongoing problem, even if you haven't received medical treatment for it. Good luck and remember, it's their job to NOT pay claims. Don't get frustrated, just be sure to ask all the questions you need to ask, including what will happen if you can't get scheduled before mid-April.

Answer 4

It means, if you were overweight when you joined the plan, on April 5th, 2008, you have to wait a year until the health insurance will pay to treat anything weight related.

In other words, although there's coverage, they didn't receive proof that you had prior coverage, so they are excluding it.  You'll have to reapply for it, next April.

Answer 5

I wish I could help you, but it looks like you are getting a mixed signal. I would suggest that you look at your benefits booklet, and confirm the definition of the pre-existing waiting period. Ordinarily it is a year, and that look's like what they are telling you. From what you quoted here, it sounds as if this surgery would NOT be covered, because it is a pre-existing condition. Don't just call them on Monday. Put your questions in writing, and fax it to them. You can call them for their fax # if you don't have it already. You didn't say if you were covered under another business policy prior to transferring to your husband's coverage. If you were, you should have received a certificate evidencing coverage. Under those conditions, the insurers are not supposed to insure you with pre-existing conditions, that clause is then knocked out.

Get an explanation in writing, then you know what you are dealing with. It is possible that you can take this further, to the insurance department in the state where you live. But, it all depends whether or not you had coverage before this policy started, with no gaps in coverage. Otherwise, you may have to wait until after April 5, 2009, and then apply for approval to have the surgery.Best of luck and good health.

Answer 6

Try to find your answer at their website.