Fighting with insurance - Pre-existing condition?
Our Lil' Family wrote: Thomas' surgery for tubes has been scheduled for next week. The Dr's office called and said it's "pending for further review of pre-existing condition"......
Backgroud:
DH was working FT, we were all on his insurance at work, Blue Cross/Blue Shield. He got accepted to Grad School, we changed from Group policy to individual policies....STILL BC/BS, effective date 12/15/05. Thomas had an ear infection in November, same infection but saw the Dr. 3 times....first visit 11/13. They send a form for the pedi to fill out regarding that...he says, it's not a problem....they accept him and cover him under individual policy. He gets another infection, saw Dr. 3 times again, first visit 12/20. All of these visits were covered still by the group plan that ended on 12/31.
So NOW they are saying they might not cover the surgery because it's a PEC! WTF? (excuse the vulgarity...I'm pissed) If DH was still working we'd still have the same group plan and BC/BS would HAVE to pay for it...the ONLY difference is that it's now and individual plan and I'm paying FOR ALL of the premium!
I'm crying my eyes out because my baby needs surgery first off and second off these jerks are deciding whether or not they can luck out and get out of paying for it since we switched plans.....how is this right?
luvmykids replied: I am sooo sorry to hear about the trouble they're giving you. We had the same experience w/ BCBS and it was a nightmare. We told them we wouldn't have even kept them for our individual policy, thought we were doing the right thing to stay with them. We finally had to get a way more expensive plan that had a more generous policy for PEC. Sorry thats not much encouragement, but you have my sympathy!
MAMACARLA replied: Insurance companies are all the same. When I got pregnant I had an HMO. Well in the third trimester my companies switched insurance companies. I went from having to pay $400 to have a baby to $3500. I still don't know how that was right.
Hopefully it will work out better for you but I understand what you're going through.
Our Lil' Family replied: What gets me is that I pay a lot of money to have private insurance for them to screw me, when I could have just put him on LACHIP (children's medicaid) and let the state pay for it, but we didn't want to do that, we wanted to pay for our own insurance....UGH!
CosmetologyMommy replied: I am sorry to here that... 
coasterqueen replied:
Same thing happened to me with Megan. With my first, Kylie she was FREE on our insurance. Then they changed the deductibles/policy revisions and bam, Megan cost me $3,000.  She was worth it though. 
LilaGrace'sMom replied: I am so sorry you are dealing with this stress. I have never cared for BC/BS for these specific reasons. What they are doing is NOT right. In the premiums paid I'm sure you have already funded the procedure and more, not to mention we are talking about a child's health. Shame on them. I wish I had more of a suggestion than hiring an insurance lawyer.
Insurance can be a good thing, yet it can also be such a drag. It has been awhile since you posted this. Do you have any news to share?
PrairieMom replied: I totally feel your pain on this. The thing about individual insurance is that they can except or deny who ever they feel like. Group insurance is forced to except everyone.
My family has individual insurance since DH owns his own business, but they wont except me becuase I have asthma. So, even tho I could be a full time SAHM, I have to work for the insurance.
They attached a 3 year rider to me. I'm not allowed to seek any medical attention for my asthma for 3 whole years, then they will reconsider my claim. Even tho I haven't been hospitialized for it for well over 10 years, and had one ER visit 9 years ago.
I HATE insurance. 
Our Lil' Family replied: Actually we just rescheduled the surgery for this Tues., 31st. They decided they would approve it but included in the letter "this is not a guarantee of payment"...guess it's their own little loophole in case they change their mind! 
Thanks for asking!
Sarah&Mackenzie replied: Well good luck, I hope that they pay for it. I can't stand insurance companies!! 
jcc64 replied:
Are you SERIOUS?? I never heard of that! That's insane. Asthma is one of those conditions that should be carefully managed and controlled so that it doesn't end up in a life threatening crisis. For a company to ask you to compromise your health like that is utterly unbelievable. Not to mention the fact that it's cost ineffective. Asthma's cheap to deal with, unless you let it deteriorate to the point that you wind up in the ER on a nebulizer or admitted b/c your blood gases are so low.
Absolutely disgusting. What insurance company is this, if you don't mind my asking?
coasterqueen replied:
Jeanne,
Yes they can do that, unfortunately. I was diagnosed with asthma right after highschool and although I've never needed to be treated except that few month incident, when I tried to seek out my own insurance when I was unemployed and going to college I was underwritten for it. It's obsurd, I know. I was thinking it was BCBS I used at that time, but it's been many many years ago.
coasterqueen replied: I wanted to add, though, that now that I'm on group insurance and see an allergist I get a nebulizer covered by my insurance. It's definitely unreal.
PrairieMom replied:
Bc/BS.
I know. It really P***** me off. COnsidering that I have moderate asthma that is extremely well controlled. I even had my Dr. send them a letter explaining my condition. I don't know if they consider my medications treatment or not, but I haven't been to the Dr. For this in 1 1/2 years, and before that is was about 6 years, so I am not worried about riding out the rider, but the whole thing is just discusting.
jcc64 replied: Insurance companies and the pharmaceutical industry- the devil in 3 piece suits- I swear to it.
It boils my blood to hear stories like this, it really does.
coasterqueen replied:
 Yep, and I work for them. 
jcc64 replied: I thought you worked for a non profit, Karen?
coasterqueen replied:
Ummm, well it is a not-for-profit, but our association lobbies for propert/casualty insurance companies and we cross over into some of the health/life (not as much) but the politics is all the same. We don't lobby for the individual, we lobby for the pocket book of the companies and those companies pay to become members for us to do that, hence where my pay check comes from.
jcc64 replied: So who do you lobby, Karen? Do you do that yourself, or is that just the mission of your company as a whole? I thought you were in event planning- is that who the events are for- industry reps?
coasterqueen replied:
Oh no, I don't lobby, thank goodness! My actual title is Business Manager. I run the office; do all the accouting/payroll; all the event-planning; take care of the Politcal Action committee funds and legal reporting; take care of all the lobbyist legal reporting and I do all legislative reporting to our members. So I work closely with legislation, I just don't lobby it or write it. I've noticed that the only way to become a woman lobbyist at least for the majority in this state, you better be prepared to sleep around.....not in my job description. 
Most events I do are wining and dining of our members - industry reps who are lawyers/lobbyists. They come and help lobby with our Executive Director. I also plan an annual event for ALL insurance reps/lobbyists (life, health, p/c, etc). And then I'm now dabbling in event planning for legislator fundraising events.
I spent last year event planning for what is called the "Third House" which is just a good ole boy lobbyist organization who like to call themselves the "third house" since the House and Senate are the other houses, lol.
And then this year I get to event-plan for all the state-wide insurance associaitions like ours, so all the other states in US will be attending.
Meeting planning is the WORST part of my job and I hate it the most. Nothing like having to put on your game face more times than you'd really like to.
LilaGrace'sMom replied:
Thanks for the update. They need to pay for it and I hope they do. I tell everyone I know not to go with an BC/BS individual plan although I suppose its with every individual plan.
It's so sad that they are not mandated to cover individual plans like group plans while it seems to be such a wonder why so many Americans do not have insurance.
Good luck with the surgery. Keep us updated on the whole situation please.
CosmetologyMommy replied: do u qualify for medicaid?
PrairieMom replied:
We went with them becuause they cover maternity. It sealed the deal for us since we were planning on getting prego, and possibly another after this one...
I hate hate hate insurance.
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