Confusing Coverage Situation - Please Help

[chefbenito]

My fellow forum readers -

I am looking for some serious advice on an insurance situation that has me confused and worried about coverage. Please take the time to review my situation, and help me out, as I am turning to the public before I seek legal advice. Thanks for your time, and advice.

In January 2008 I suffered a serious work related injury. My leg was was crushed in an accident with a machine, and I spent a month in the hospital and the next year recovering. Everything was covered under my workers' compensation insurance (a separate company from my normal health insurance policy with Blue Cross). After a remarkable recovery, and getting back to a very normal life with a few limitations, I decided to settle with the workers' comp agency. Just to make it clear to you all, in December 2010 I signed away my right to "any further medical treatment" and my "right to any additional benefits if my condition worsens as a result of this injury." Workers comp insurance has no more liability, PERIOD.

As luck would have it, 2 weeks after signing those papers I felt a bump in my knee. I thought it was a loose screw from the operations. I went to my orthopedic surgeon, and he confirmed it. The doc said that it was up to me whether or not to have it removed, but the screw wasn't going to get any tighter. The doc's office billed through Blue Cross (my normal health insurance company since 2006) - I paid the copay, and the visit was covered. Bottom line, I want this screw out of my leg, and I don't want to get denied after this minor surgery. I can have this procedure done in the triage unit of my doctor's office building. I have the option of having a local anesthetic instead of being knocked out during the procedure.

I called Blue Cross just making sure that this was now part of their coverage since I no longer had Workers comp. I began to realize that whomever I was talking to was going to be on the defensive for Blue Cross. They referred me to my plan Exclusions; one of which stated - "Services or supplies for any illness or injury arising out of or in the course of employment for which benefits are available under any Workers' Compensation Law or other similar laws whether or not you make a claim for such compensation or receive such benefits." The agent also informed me of possible troubles due to this being a "pre-existing condition."

I called my doctor's staff with the concerns from Blue Cross. They said that if I had to self-pay for the operation that they would cut some costs. It is still estimated around $4,000.00 though .... a far cry from my deductable.

Here are some definitions from my policy that will help with my following questions.

PREEXISTING CONDITION "means any disease, illness, sickness, malady or condition which was diagnosed or treated by a Provider within 12 months prior to your Coverage Date, or which produced symptoms within 12 months prior to your Coverage Date which would have caused an ordinarily prudent person to seek medical diagnosis or treatment"
COVERAGE DATE "means the date on which your coverage under this policy began"

Finally, here are my questions:

1) Do I have a pre-existing condition? I can't tell if "coverage date" means when I was originally given the policy in 2006, or if it means when I renew it every year. If Coverage Date means 2006, then I don't see how it can be "pre-existing" if this accident happened in 2008.

2) Do you think I'm covered by Blue Cross given the information I've provided? I've given up my rights to benefits from Workers' Comp through another insurance company, but how can I go on without ever getting treated for these issues? I'm only 28, but when I am 50 and have another loose screw, are they still going to be saying that Workers Comp is responsible for an accident 25 years ago?

3) Am I setting a precedent if I have to pay out-of-pocket? I am worried that I will jeapordize future appointments or concerns if I pony up the $4,000.00 and pay for it the first time. Again, what if a procedure is $25,000.00 when I'm 50?

4) How should I proceed with my doctor/surgeon? If I file this claim through Blue Cross from the start, the cost will be much more than the deal the doctor gave me if I have to pay out-of-pocket. If I go through with the procedure as a self-pay, then I could still go back to the insurance company and try to file it after-the-fact. I am worried that this will encourage them to deny it more easily though, since it's coming from me, and not the doctor's office.

5) I can always file a claim review if I am denied. Do you see any grounds for this if it should take place?

6) Any other advice?

Thank you for your time, and insight. I never had to think about how much it would cost to take care of myself until now - which is why I am full of details and questions.

 

[Crabcake Johnny]

First of all, you need legal advice and nothing you get from this board is going to qualify as legal advice.

Here's my opinion...which with $2.00 gets you a cup of coffee. Yes, there is a clause is most policies that excludes coverage for work-related injuries if workers comp is supposed to foot the bill.

In your case, workers comp is supposed to foot the bill and that you stuck a deal with the company to "settle" basically isn't the carrier's problem.

 

[Guest]

Should not be be a pre-existing condition for your health insurance carrier since the treatment took place during the coverage period. If your employer does not have a HR Dept and you have to deal with the health insurance carrier direct write your health carrier claims dept. and provide copies of the signed workers' compensation release forms. It is time you have paper trail. Good luck!

 

[somarco]

If your Blue coverage is a group plan there should not be any pre-ex limits unless you had a break in coverage. An exception would be, since this started as a WC claim it was never their claim to begin with and would not be their claim in the future.

If this is brand new individual coverage it very well could be a pre-ex condition and not covered.

When you signed a waiver for future medical expenses you agreed to accept liability.

 

[HealthGuy]

Has anyone noticed a 100% increase in these types of posts since health reform started really kicking in say six months ago? Is this a SURPRISE since 90% of good agents just bolted this business? Another unintended consequence of the Obamination. Thousands of uninformed, unhelped consumers floundering with less advice, less choices. Way to go Obama. Your poopie diaper continues to smell to high heaven. Why doesn't Obama begin to help these people?

 

[arnguy]

First of all, you need legal advice and nothing you get from this board is going to qualify as legal advice.

Here's my opinion...which with $2.00 gets you a cup of coffee. Yes, there is a clause is most policies that excludes coverage for work-related injuries if workers comp is supposed to foot the bill.

In your case, workers comp is supposed to foot the bill and that you stuck a deal with the company to "settle" basically isn't the carrier's problem.

Spot on advice!

 

[chefbenito]

Thank you for your advice everyone. At the time of signing my settlement, I was told by a handful of people that I trusted that it was theright thing to do. I don't blame anyone for my decision, but I wish I had the opinions I'm receiving now before I signed the paper. I never needed the settlement money, nor do I care about it. It's not life-changing money. The hours I've personally spent looking into my situation wouldn't have taken place before I signed i guess. I wish I had asked an attorney to look at my comp settlement in the first place, and not relied on those that I thought had enough knowledge to guide me in the right direction. Although I will still look into legal advice, if this turns out to be a situation where I am not covered, I will have learned one of my biggest life lessons. As a person who's had health insurance their entire life, I will now know what it's like to live life cautiously, and worried like those who don't. I hope that someone comes to me when they need advice about insurance in the future. The first thing I will tell them is to lawyer up, and don't sign anything.

 

[ABC]

Tough break.(no pun intended)
Once you cashed that check the workers comp was free and clear.

 

[briko3]

Hopefully you still have enough of that money to cover the procedure.

 

[leevena]

My fellow forum readers -

I am looking for some serious advice on an insurance situation that has me confused and worried about coverage. Please take the time to review my situation, and help me out, as I am turning to the public before I seek legal advice. Thanks for your time, and advice.

In January 2008 I suffered a serious work related injury. My leg was was crushed in an accident with a machine, and I spent a month in the hospital and the next year recovering. Everything was covered under my workers' compensation insurance (a separate company from my normal health insurance policy with Blue Cross). After a remarkable recovery, and getting back to a very normal life with a few limitations, I decided to settle with the workers' comp agency. Just to make it clear to you all, in December 2010 I signed away my right to "any further medical treatment" and my "right to any additional benefits if my condition worsens as a result of this injury." Workers comp insurance has no more liability, PERIOD.

As luck would have it, 2 weeks after signing those papers I felt a bump in my knee. I thought it was a loose screw from the operations. I went to my orthopedic surgeon, and he confirmed it. The doc said that it was up to me whether or not to have it removed, but the screw wasn't going to get any tighter. The doc's office billed through Blue Cross (my normal health insurance company since 2006) - I paid the copay, and the visit was covered. Bottom line, I want this screw out of my leg, and I don't want to get denied after this minor surgery. I can have this procedure done in the triage unit of my doctor's office building. I have the option of having a local anesthetic instead of being knocked out during the procedure.

I called Blue Cross just making sure that this was now part of their coverage since I no longer had Workers comp. I began to realize that whomever I was talking to was going to be on the defensive for Blue Cross. They referred me to my plan Exclusions; one of which stated - "Services or supplies for any illness or injury arising out of or in the course of employment for which benefits are available under any Workers' Compensation Law or other similar laws whether or not you make a claim for such compensation or receive such benefits." The agent also informed me of possible troubles due to this being a "pre-existing condition."

I called my doctor's staff with the concerns from Blue Cross. They said that if I had to self-pay for the operation that they would cut some costs. It is still estimated around $4,000.00 though .... a far cry from my deductable.

Here are some definitions from my policy that will help with my following questions.

PREEXISTING CONDITION "means any disease, illness, sickness, malady or condition which was diagnosed or treated by a Provider within 12 months prior to your Coverage Date, or which produced symptoms within 12 months prior to your Coverage Date which would have caused an ordinarily prudent person to seek medical diagnosis or treatment"
COVERAGE DATE "means the date on which your coverage under this policy began"

Finally, here are my questions:

These questions are relatively easy, you may not like the answers though.

1) Do I have a pre-existing condition? I can't tell if "coverage date" means when I was originally given the policy in 2006, or if it means when I renew it every year. If Coverage Date means 2006, then I don't see how it can be "pre-existing" if this accident happened in 2008.--No, you do not have a prex. Also, as an fyi, re-read your document, most group plans that have a prex have a time limit on it, usually 12 months.

2) Do you think I'm covered by Blue Cross given the information I've provided?--Yes, you are covered, but not your workers comp related expenses. I've given up my rights to benefits from Workers' Comp through another insurance company, but how can I go on without ever getting treated for these issues?--You can and probably will be covered by a commericial carrier in the future. Remember something, your current carrier knows that it's WC related. But in the future, the new carrier will have a much more difficult time knowing that. There is no way (currently and in the foreseeable future) for a new carrier to in a few years to know it is WC. I'm only 28, but when I am 50 and have another loose screw, are they still going to be saying that Workers Comp is responsible for an accident 25 years ago?

3) Am I setting a precedent if I have to pay out-of-pocket? I am worried that I will jeapordize future appointments or concerns if I pony up the $4,000.00 and pay for it the first time. Again, what if a procedure is $25,000.00 when I'm 50?Precedent for what? If you show up later with a different illness and the carrier covers you what's the big deal? When your 50 and the bill is $25k, how will the new carrier, which is probably your 7th new carrier by then, going to know?

4) How should I proceed with my doctor/surgeon? If I file this claim through Blue Cross from the start, the cost will be much more than the deal the doctor gave me if I have to pay out-of-pocket. If I go through with the procedure as a self-pay, then I could still go back to the insurance company and try to file it after-the-fact. I am worried that this will encourage them to deny it more easily though, since it's coming from me, and not the doctor's office.--Tell the doc and BCBS the situation. You can obtain a determination from BCBS ahead of time. Denial has nothing to do with where it came from, you or the doctor.

5) I can always file a claim review if I am denied. Do you see any grounds for this if it should take place?--This is your call, but based on what you have outlined here, they are going to deny it.

6) Any other advice?--yes, don't listen to your friends. Next time spend the $500 and go to an attorney.


Thank you for your time, and insight. I never had to think about how much it would cost to take care of myself until now - which is why I am full of details and questions.

I do wish you luck in working through this issue. Don't be too worried, it will work out and you will find that your concerns were not that big of a deal.