concerned about new HMO plan denying benefits

[hwan]

I am a maryland resident. i recently had a short-term plan, during the course of which i was diagnosed with a tumor (benign) in my ear. i had it removed, and it was covered. i need a followup surgery in august or so. my short-term policy ends on july 1. i have since joined an individual HMO plan with CareFirst in maryland. of course, i disclosed the ear tumor on my application. however, one thing concerns me and i think might be a basis for CareFirst trying to deny benefits based on my failure to disclose information.

i took a look at my application yesterday to make sure i had disclosed everything correctly and i accidentally noted the condition as "fully" recovered. but i also put the dates of treatment as april 2007-july 1, 2007. my coverage started june 1, 2007. additionally, CareFirst asked me to submit a medical report form to my doctor to fill out, which he did. i have requested a copy of that, which i am waiting for, but i have to imagine he noted on there that i needed a followup surgery. given the fact that i noted that i needed treatment until july (when i thought i was going to get the surgery, but my dr is on vacation then and failed to mention that), AFTER my coverage began, and given the fact that my doctor must have clarified that i need a second surgery, does anyone have any thoughts on whether they might try to claim that i did not disclose my condition? they are on really shaky ground in doing that, but i wanted to see what others might think.

i am not worried about them excluding a preexisting condition, as HMOs in maryland are not permitted to do so, from my understanding. thanks.

[moburkes]

Is this an individual policy? If they are not allowed to exclude pre-existing conditions, then they would not deny coverage, they would simply cancel your policy. They would only cancel the policy, though, if it would not have been written had they known that information upfront.

[hwan]

yes, it is an individual policy. i understand what their basis would be for either denying me or canceling my policy, but i am curious, given the circumstances above, whether anyone with any experience with health insurers think they might try to claim i withheld information from them. they certainly cannot say they didn't know about the condition, and i disclosed that i would need treatment for the condition until july 1, when is when i wanted my coverage to begin. instead, they put my policy in effect on june 1. having said all that, i was quite surprised they approved my application. they are going to foot a bill for several thousand dollars (i am assuming they get substantial discounts from my doctor), and i pay 100 bucks a month. they basically made a bad investment. which is why i am concerned they are going to search for a reason to deny me or cancel my policy.

i wonder whether there is anything i can do to find out ahead of time whether they would give me problems with this by calling them in advance. probably not, though.

[moburkes]

Call them****************************

[hwan]

argh, i did just call them, and that got me nowhere. they need all sorts of procedure codes, which they will only get when my doctor calls them for surgery preauthorization. i suppose i should somewhat prepare myself for an appeals process and lawsuit.

[moburkes]

If they cancel you it will be before August.

If they don't cover the surgery, that will be in your handbook. You don't need to wait to have the surgery to figure out what procedures are covered.

[hwan]

i don't think they would cancel my policy until they found out i needed an operation, at which point, if they DO try to cancel me, they might do so on the basis that either i or my doctor omitted info on the application that would have caused them to deny my app. they know of my tumor, so there is no concern that they are going to claim they didn't know about that, but that when they hear about the second operation, they might say "gee, we didn't know about this; you indicated that you'd be fully recovered by july 1." my doctor just told me that my need for a second surgery wasn't decided until june 6, last week. i think might be in my favor, as it was after coverage began. there was nothing to disclose until june 6, and my coverage had started by then.

as far as the procedure itself not being covered, i see nothing in the handbook that would suggest that is the case. i suppose they could somehow claim it is not medically necessary, but that is a real stretch, so that doesn't concern me.

[moburkes]

I don't have time for this today**************...

[hwan]

well, ask the guy with the gun at your head if you can stop replying to me.

[moburkes]

Originally Posted by hwan

well, ask the guy with the gun at your head if you can stop replying to me.

Did you come to here to get information, or give it? When I post a thread asking for advice, you're welcome to respond. However, don't hold your breathe waiting for responses when you have a bad attitude.

[hwan]

i came here to get input, quite frankly, which involves a dialogue with anyone who wishes to engage in it. i pose a question, a discussion starts. i am looking for people's thoughts. people who might have more experience with health insurers than i. i'm an insurance defense attorney, and my firm deals with commercial liability insurers; i've seen them try to deny coverage on some pretty flimsy bases. i'd guess attorneys or at any rate people with experience with health insurers might have some good insight into my situation. hence my thread. i never displayed a bad attitude until you said "i don't have time for this." what was the point of your saying that, other than to come off as rude and dismissive?

[moburkes]

Then, prepare for your appeal, Mr Insurance Attorney.

[hwan]

you probably won't bother to answer me, but why is it that you feel they are going to deny me and trigger an appeal?

[lealea1005]

Here's the way I see it hwan....you can do additional footwork and see if your surgeon will give you the ICD9 and CPT codes he intends to use for your surgery and then call your insurance company back.

Ultimately, YOU are responsbile for paying anything your insurance denies or doesn't cover. Just because your insurance company tells you they "cover" a service doesn't mean it guarantees payment of the service.

[lealea1005]

Originally Posted by hwan

i am not worried about them excluding a preexisting condition, as HMOs in maryland are not permitted to do so, from my understanding. thanks.

You'd better check on that. That may be true for large group plans but not individual plans.