Claims denials - Pre-existing Condition

[VoodooDali]

New Jersey
I am self-employed and purchased individual insurance in January.
I did not have insurance for 10 years prior to this. Thus, ERISA and COBRA do not apply to me, nor does much of HIPAA.
I went for my annual ob/gyn appointment. I reported that my periods were heavy and had been for the past 8 years. I had not sought medical advice for this because I thought it was just the way I was. I reported it to the ob/gyn because I wondered if it was a pre-menopausal symptom. The doctor decided to do a pelvic ultrasound and hysteroscopy with endometrial biopsy to rule out cancer. It came back negative. The plan was to do a procedure called endometrial ablation, but the insurance company will not give pre-approval for it. On top of that, the insurance company is denying the claims saying that the heavy periods are a pre-existing condition.
Under my policy, it states that a pre-existing condition is a condition that has been diagnosed in the past 5 years (this was not); or a condition for which a "reasonable person" would seek medical advice. The last part of this clause seems awfully broad to me, but I never thought that my periods were that uncommon or worth seeking medical advice for.
Is the law on my side or the insurance company's?

Also, if this has not been enough to deal with...I had my first mammogram (I am 43), which the insurance company is required to pay for by state law. The mammogram came back abnormal and now I have to go in for a biopsy to determine if I have breast cancer. Will I be dealing with the same issue? The abnormality found is not one that can be found through breast self-exam and was not found in the doctor's clinical breast exam. It can only be seen on a mammogram. Can they say it was pre-existing because I should have had my first mammo 3 years ago? I've heard they've used this argument against people with HIV/AIDS (that HIV was pre-existing because the person could have been tested for it years before).

Doesn't this "reasonable person" clause give the insurance companies a blank check to deny all claims to the newly insured?

[Betty]

Hi. Could you tell us, please:
1) The effective date of the insurance coverage you purchased in Jan.
2) The date you first had a consultation for each of the two conditions you mentioned.
Thanks
(Generally speaking, a pre-existing condition is a condition for which a person is receiving treatment, has been advised to receive treatment, or for which a prudent person would seek treatment.)

[ecmst12]

Generally speaking, if you had never received or sought treatment for these conditions before, they would not be considered pre-existing. But the best way to find out for sure is to call the insurance company and ask. I think you're probably safe though. As long as you didn't lie on your application or anything like that, I don't think they'd consider your actions unreasonable; most people wouldn't seek treatment for something they consider an annoyance when they don't have insurance.

[somarco]

Pre-ex definitions vary by company and state. What applies in GA may not be so in NJ.

In your situation, claiming I had not sought medical advice for this because I thought it was just the way I was is enough to allow some carriers to deny the claim.

The bailing clause is cited by you . . .
or a condition for which a "reasonable person" would seek medical advice.

(According to you) your flow did change 8 years ago. That would have prompted a reasonable person to seek advice. You did not.

As to the other issue, it is possible that the carrier can deny that claim as well. Even though it was (apparently) not prompted by symptoms, there is some wiggle room, but not as much as with the GYN issue. The fact that you went naked (no insurance) for 10 years and further failed to take advantage of routine exams at your expense should not be a factor in denying future claims for breast problems.