Should my wife's medical condition be considered pre-existing?

Question

My insurance company (Humana) is denying to pay for my wife's medical bill stating that it was a pre-existing condition. My wife and I married in September of 07'. She came onto my insurance in October of 07'. Before this time, she had no insurance. At the time of our marriage, my company was insured with Kaiser PPO. However, In March of this year (08') my company switched insurance companies to Humana (with no lapse of service)...While we were yet with Kaiser, my wife was diagnosed with a goiter that is non-malignant but just needs to be watched...as part of watching it, my wife saw her Thyroid Dr. after we switched to Humana, and now Humana is refusing to pay for that office visit...is that legal?...thanks sooooo much for any and all help! Jim

Answer 1

This sounds like a job for HR

Answer 2

yes, it can be considered a pre-existing condition since your wife has only had coverage for 5 months before going on the new plan.  If she didn't have insurance before October 07', she only has had coverage for 7 months so far.  

Your wife would have to show 18 months of credible coverage with no more than a 60 day break in coverage for there not to be a pre-existing condition limitation.  

I'm surprised the insurance company caught this though, since your wife was on the prior carriers plan, but they did and it is legal.

Answer 3

No-this cannot be considered pre-existing. Go to your HR dept and have them straighten it out with Kaiser.

Answer 4

Yes, it's a pre-existing condition. She doesn't have 12 months of prior credible coverage - she only has since October of 07.  She's got to wait it out.

Answer 5

If there was a lapse in the policies yes it can be considered pre-existing.  The insurance company will do anything to get out of paying.

Answer 6

Your wife will have to meet Humana's preexisting condition limitation cause before they will pay for any medical condition she had prior to October 1, 2007.

If Humana's preexisting condition limitation cause is 12 months, they will begin to expenses related to her goiter on November 1, 2008. If Humana's preexisting condition limitation cause is 18 months, you will have to add another 6 months on to that before Humana begins to pay for expenses related to the condition.

Check a copy of your benefit booklet to determine the exact length of the preexisting condition limitation cause or if you don't have a booklet see your HR department.

Answer 7

A wide range of answers. 12 months. 18 months. Let's decipher it.

18 months is usually the length of time you have Cobra and 12 months is generally the period of time used in determining the pre-existing condition clause.

Your best bet is sometimes to check with an EXPERIENCED broker...

I hope this helps.

27 years in the business.