Pre-existing condition (some talk of former m/c mentioned)

doremi · #1 November 17th, 2011, 11:40 PM

Has anybody else dealt with their insurance companies labeling something a "pre-existing condition" in relation to their OB care? I had my second m/c the beginning of September, and we switched insurance companies when my DH got a new job. Our new insurance went into effect Oct. 1st. After my m/c, I was having extremely heavy periods, and my OB ordered a regular and vaginal u/s to rule out the possibility of fibroids/cysts, or any other medical issue in my uterus. I had the u/s the end of October, and just got something in the mail this week from the insurance company requesting proof of insurance for June-September of this year, and other medical information. They are suspending the claim on the u/s until they do more digging because it has been flagged as falling potentially under the "pre-existing condition" clause of my contract. I got a second letter today, and found out that if they decide not to pay it, the bill is going to come to almost $1300 out of pocket for us

I'm really freaking out. We already had almost $1000 in medical bills from my first miscarriage thanks to having to seek care out of network initially, and having crappy insurance. Now this. I'm just sick about it. You would think that even if they DID want to link the u/s to my miscarriage (which isn't really fair since it wasn't directly related), that they should have to cover miscarriage care the same as they legally have to cover prenatal care when you switch insurance companies. It just isn't fair. Ugh. That is my rant. And sorry I haven't been checking in much... I found when I was on here more often it was kind of making me obsess in a not so good way about getting pregnant. I let myself get into a dark place for awhile, and just needed a bit of a break from TTCAL... I'm sure you all understand how that goes

I should be O-ing again in a few days, so we will be bd-ing like crazy. I'm hoping to find out I'm pregnant towards the beginning of December... so ready for the TTC part to be OVER!!!

.:Shortcake:. · #2 November 18th, 2011, 03:47 AM

Insurance companies can be VERY frustrating. It honestly could be from the way your doctors office billed it. I know before my insurance didn't want to cover something and the doctors office changed the code and it was covered. There are lots of gray areas. If I were you I would call the doctors office and speak to their billing department. They might be able to help you determine if there was a coding issue or if they can code it another way that it will be covered. I'm not sure if it's coded diagnostic then how they would consider it per-existing.

pepper73 · #3 November 18th, 2011, 04:23 AM

I'm so sorry! That really sucks and dealing with insurance companies is a nightmare! I agree with Katie about contacting your doctor's office. I hope you are able to get this resolved soon.

Good luck this cycle!!! I hope you catch that eggie!!

3Sapphires · #4 November 18th, 2011, 04:59 AM

did you have a lapse in coverage? if so they can deny anything for just about any reason.

insurance companies SUCK! there used to be a time when doctors billed patients a reasonable amount for services and patients paid it. none of this crap where the doctor inflates the cost, so that the insurance company will pay 1/3 of the "cost".

blah anyway

if you do end up getting stuck with the bill and and ask for a discount - it isn't fair for the doctor to pass on an inflated price to you and expect you to pay it when they don't expect to get paid the full amount from the insurance company.

joanna26 · #5 November 18th, 2011, 05:36 AM

I totally agree with Katie. It could be the way they coded it. Because otherwise I don't know why a vag u/s would have raised any flags for them. But Ami is also correct that if you had a lapse in coverage they can deny a lot of things initially for very little reason. If you end up having to pay the bill definitely call you OB and explain the situation. I bet you get a big discount. That is a ridiculous price for an u/s.

K.A.T · #6 November 18th, 2011, 07:22 AM

I'm sorry that has to be frustrating. I too, agree with Katie.

sandiegomom · #7 November 18th, 2011, 08:00 AM

They most likely coded the u/s with the m/c diagnosis. they CAN change that. They should change it to reflect a "rule out fibroids... or whatever they are trying to rule out code" Being a nurse, I will tell you that YOU are in charge. please don't let an insurance co. scare you. they want and count on that. trust me from experience. I have had things denied and when i have called the insurance co, ranting about why they can not deny it and have intelligent information to back it. they always back down. talk to a supervisor if you need to. m/c's are never a pre-existing condition. if the u/s was to ensure a m/c was completed, it could be denied, but that is it. they can not just deny you for any reason because you had a lapse in coverage. there are very specific guidelines to pre-existing conditions. Just be sure and fight them tooth and nail. They are trying to rule out possible causes for m/c's and that is not pre-existing by any means....even if you had the m/c with no insurance. stick to your guns. don't let the insurance company scare you into thinking what they are telling you is "just the way it is", because that isn't necessarily true. I am sorry for your added stress, that always sucks. i hope you get your rainbow baby soon!!

doremi · #8 November 18th, 2011, 09:29 AM

I had insurance when I had my m/c, then a 2 week lapse in coverage towards the end of September. I'm planning on calling my OB today.

ninja_mommy · #9 November 18th, 2011, 12:58 PM

Insurance is such a PITA to deal with! Glad you are back to trying again!

doremi · #10 November 18th, 2011, 01:29 PM

YAY! I talked to Aetna this morning, and once they confirmed with my previous insurance company that I had had coverage at the time of my last miscarriage, they submitted the u/s claim for reprocessing, and said that they don't anticipate any problems with it going through. PHEW.