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Existing Condition

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kayumochi

Junior Member
What is the name of your state? GA

Here is my situation: in the midst of making a move from Japan (where I am self-employed) to Atlanta, Georgia I find out that I have a health condition that would make it impossible for me to get affordable gap insurance while I look for a job with sound medical benefits. I do not need any treatment now but may in the future.

Now, no one in the USA knows I have this condition. No records exists, medical or otherwise, that state or even hint that I have this medical conditon. Could I just keep quiet and try to get this gap insurance anyway? I doubt that I would even use it, but want it for my family's sake.

My next question: could I take this even further and later be "surprised" by a diagnosis? Could I be found out?

I am quite willing to get an insurance attorney to help me with this. Would it be worth my while to do so?
 


pojo2

Senior Member
If you are going to commit fraud I doubt you will find anyone else willing to jump on the bandwagon.

If a question exists on the document asking about known existing illness and you answer NO you are committing fraud.

You might get by with it on the GAP but if you get employment where "job with sound medical benefits" you will more than likely have to have a physical.
 

kayumochi

Junior Member
Isn't it illegal to discriminate during the hiring process based on the applicant's health? I cannot recall having to take a physical in any corporate job with sound medical benefits I ever had.

I realize it is fraud. However if I do not get sound medical coverage thru an employer who can provide community rates it might mean that I spend the rest of my life in Japan. So you see I have to consider all my possibilities.
 

cbg

I'm a Northern Girl
Have you had medical treatment for this condition? If not, it is not fraud. The definition of a pre-exisiting condition is one for which you have been treated (this includes medication) during the look back period. The look back period cannot be longer than 12 months if you are obtaining employer-sponsored group insurance (18 months in some very limited conditions) and state law can be shorter.
 

kayumochi

Junior Member
cbg said:
Have you had medical treatment for this condition? If not, it is not fraud. The definition of a pre-exisiting condition is one for which you have been treated (this includes medication) during the look back period. The look back period cannot be longer than 12 months if you are obtaining employer-sponsored group insurance (18 months in some very limited conditions) and state law can be shorter.
Interesting. No, I have no had medical treatment for this condition (and none is required at this time). So if I am asked a question regarding a pre-existing condition/illness and answer "no" I am NOT committing fraud?

Is there a "mechanism" that a US insurance company could have access to Japanese medical records. It seems improbable but...
 

cbg

I'm a Northern Girl
Clarification:

If you are asked if you have been treated for such and such a condition, you can answer no and it will not be fraud. If you are asked whether or not you have ever been diagnosed with such and such a condition, it is fraud if you say no.

They are not going to ask about "pre-existing conditions" in the abstract. They are going to be asked if you have ever (been treated for OR been diagnosed with) a long list of specific conditions, to which you will answer either yes or no. You will have the opportunity to offer an explanation for any conditions to which you answer yes.

Note that saying yes, you have been diagnosed with such and such a condition will NOT automatically result in insurance being denied. It MAY result in your premium being raised. Much depends on exactly what the condition is. In my state (though not in all states) you CANNOT be declined for employer-sponsored group insurance, though a pre-ex clause can be applied and/or your premium can be increased.

The insurance carriers will not have access to Japanese medical records, and under US law even if they did, they could not access them without your written consent.
 

lkc15507

Member
kayumochi said:
What is the name of your state? GA

Here is my situation: in the midst of making a move from Japan (where I am self-employed) to Atlanta, Georgia I find out that I have a health condition that would make it impossible for me to get affordable gap insurance while I look for a job with sound medical benefits. I do not need any treatment now but may in the future.

Now, no one in the USA knows I have this condition. No records exists, medical or otherwise, that state or even hint that I have this medical conditon. Could I just keep quiet and try to get this gap insurance anyway? I doubt that I would even use it, but want it for my family's sake.

My next question: could I take this even further and later be "surprised" by a diagnosis? Could I be found out?

I am quite willing to get an insurance attorney to help me with this. Would it be worth my while to do so?
I think the operative words here are HIPAA and Creditable Coverage. I will not pretend to know if you have creditable coverage from your employment in Japan that would satisfy HIPAA guidelines. But, to the rest of your post, if you are asked and you falsify any insurance documentation, you are at risk of finding any and all health care claims denied (the least of possible worries). Your eligibility under any employer group plan will be ka put. Even if no records exist in the US, an insurer, without evidence of insurability or creditable coverage will ask for your medical records. You might get away with lying. But if something comes up later that even hints at a prior diagnosis, you will be toast. Lying might get you insurance coverage for now, but if discovered.....OWWWW. Perhaps even serious trouble. Truth might get delay of coverage but it is the best option. Eventually, if you are covered by an employer group plan, even if conditions are excluded for a period, those same conditions should eventually be covered if you maintain creditable coverage according to HIPAA. Lkc15507

I want to add that cgb is absolutely correct. But the only qualifier that I will add is something I did not make absolutely clear in my post. Even if you are successful in hiding any diagnosis made in Japan, certain medical conditions and the current status will point toward a time frame of the existence of the condition. IE your new US medical records would have to indicate a new diagnosis, otherwise a preexisting diagnosis will be assumed and sought. Again, cbg is right that any existing diagnosis may not preclude coverage, except if you lie about it and are caught. lkc15507
 
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james2med

Junior Member
cbg said:
Have you had medical treatment for this condition? If not, it is not fraud. The definition of a pre-exisiting condition is one for which you have been treated (this includes medication) during the look back period. The look back period cannot be longer than 12 months if you are obtaining employer-sponsored group insurance (18 months in some very limited conditions) and state law can be shorter.
Does "treated" also include MRIs to track a condition?
 

cbg

I'm a Northern Girl
Yes, it does. Or at least, if the insurance carrier chooses to consider that treatment, they may.
 

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