Insurance Question (pre-existing)

Message

#1 Post by **krokdteeth** » Mon Mar 24, 2008 3:15 pm

I have had previous creditable coverage so this may not apply to me, but I would still like to know what this means...in English

"Medical expenses for a pre-existing condition are not
covered for the first 365 days after the memberâ€™s effective
date. Lookback period for determining a pre-existing
condition (conditions for which diagnosis, care or treatment
was recommended or received) is 6 months prior
to the effective date of coverage."

Suppose I have had this insurance for less than 1 year, but I have never been diagnosed or suggested to
get this surgery done. If I go to the doctor saying that I have x and y problems and he suggests
surgery, how does that work? They do cover it under
certain circumstances and I believe I fit them.

Thanks,

#2 Post by **allisonh** » Mon Mar 24, 2008 4:13 pm

First thing is first... is TMJ/oral surgery an exclusion (as it was in my case). If it is excluded from your policy, it may not matter if it is pre-exhisting or not.

If you are unsure, ask your insurance company.

Gosh, insurance shouldnt be this complicated, but then again, I think I have had the worst insurance situation possible. Our insurance wont pay for anything! Even though we got their most expensive policy available!

#3 Post by **badbite** » Tue Mar 25, 2008 10:11 am

I f the insurance covers it at all, it sounds like it would be covered. You were never diagnosed.

#4 Post by **krokdteeth** » Fri Mar 28, 2008 4:02 pm

Thank you to all. I do have Aetna and a very comprehensive policy as well. They do cover it if not "cosmetic" and with what I have read, they are much more liberal than BCBS etc in covering it (doctors answering a survey gave their opinion.) Reading the conditions under which they would cover it, I think I match them more than one circumstance... and then some.

Question: I have had braces before (quite a few years ago,) but as you know, with a jaw problem, the position is not stable. Do I go to an ortho first or to a surgeon? I need a referral for the surgeon from my doctor, as I have an HMO. If the doctor sees it as a lost cause with Aetna, I then am still officially diagnosed. Unless I ask him to unofficially guesstimate with a nod when I go to see him for another problem. For the record: I had Aetna for the past 4 years, but under a different plan and never used them, so they got their money

and this is bothering me as the position is getting worse.

Thnx

#5 Post by **badbite** » Fri Mar 28, 2008 4:57 pm

I think I'd go to the Orhto first. You'll probably have to be braced again, and the ortho can help you find a surgeon. If you need a referral, the ortho's office should help you get that from the doctor. I asked my OS not to put anything about TMJ on my record and he complied.

#6 Post by **krokdteeth** » Sat Mar 29, 2008 1:24 am

Thanks. I'll bring the isuance guidelines with me, they are vey specific about when they cover the jaw surgery