Re: Insurance Question - Pre-existing condition...

[Guest guest]

First, consider the possibility that your exisiting doctor may be

right in deferring surgery, depending on your condition and the type

of surgery being considered. It's my understanding that much of the

surgery done for CP (as opposed to other knee problmes such as torn

menisci or ligaments)is not sucessful or is only temporarily

sucessful.

Did you ever get a thorough exam through Kaiser where they were

looking for biomechanical deficiencies throughout the lower part of

your body? If not that may be the place to start. Even if you have

to go outside your plan and pay the full cost out of your own pocket

it will be much less expensive then surgery.

The more I learn about CP, the more I think CP is just a symptom of

something else wrong in the body either above or below the knee. The

problem(s) can be very differnet in different people. The

precipitating factors can be anything (or more then one thing) from

your feet up to your lower back.

Many (probably most) doctors either lack the ability or the time to

try to determine what your unique problem is. Instead they follow a

cookie-cutter treatment approach for all their CP patients. This may

work a lot of the time, but won't work for everyone, because it may

not be applicable to your unique condition.

I finally put my money where my mouth is and went outside of my HMO

and saw someone competent who spend a few minutes on an actual exam

and found a lower back issue that no else had even considered the

possibility off.

Also, look carefully at what the definition of " pre-existing

condition " is. This definition can vary from state to state or from

insurer to insurer. There is no standard definitin.

I would expect that even if you pay out of pocket for the surgery

and the surgery is sucessful and you don't need further treatment,

you will STILL be considered to have a pre-existing condition for a

while. For example, see one diffinition used by one insurerer below.

Also since you are already planning on getting some type of group

insurance, the whole " pre-exisiting condition " problem may not even

be an issue from you, as the HIPPA law forbids this if certain

conditions are met. See if HIPPA applies to you:

http://print.disabilitybenefits101.org/ca/programs/your_rights/hipaa_a

b1672/hipaa/faqs.htm

One definition of " pre-exisiting condition: "

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http://www.medplanaccess.com/anthem/pre_existing_conditions.htm

Anthem Blue Access

Pre-Existing Condition Exclusion

Under Anthem Blue Access Indiana Health Insurance coverage, a pre-

existing condition is defined as

(1) a condition for which medical advice, diagnosis, care, or

treatment was recommended or received during the twelve (12) months

immediately preceding the member's effective date under the Anthem

Blue Access policy, or

(2) a pregnancy existing on the member's effective date under the

Anthem Blue Access policy, if maternity related benefits are provided

under the policy.

Under the Blue Access plans, Anthem will not cover any sickness or

injury which is caused by, or results from, a pre-existing condition

in the first 12 months of coverage under the Anthem Blue Access

health insurance policy.

Exception: For pre-existing condition exclusion purposes, Anthem

will credit the time a member was covered by prior creditable health

insurance coverage under a comprehensive major medical plan. This is

a legal requirement created by the Health Insurance Portability and

Accountability Act of 1996 (HIPPA). To determine your determine

your " HIPPA eligibility, " access the federal government's HIPPA

Online website.

=====

> I am self-employed and have had Kaiser insurance for the past 4

> years through a group organization called SBSB.

>

> I was diagnosed with PFS in 2000. The good-for-nothing Kaiser

> orthopedic doc first gave me a prescription for Motrin, sent me for

> P/T and told me there was nothing that they could do for my knee.

> Last year, same doc gave me Hyalgan injections. This past April,

> same doc said that she was going to refer me to a surgeon. After

an

> MRI, same doc calls me up and says that she thought " we " should

> remain conservative in treatments and just go with Hyalgan

> injections again....which only lasted until June.

>

> Suddenly, my monthly insurance premium rates have jumped from

> $350/mo to $635/mo.

>

> When I applied for Kaiser's " personal " insurance plan at a monthly

> premium rate of $271, I was rejected based on a pre-existing

> condition....which I think largely is due to the fact that I let

the

> orthopedic doc put off surgery.

>

> My question is: Does anyone else that is self-employed with this

> pre-existing PFS/Chondromalacia condition have any reasonable

> premium cost insurance company recommendations where I wouldn't be

> rejected based on it being pre-existing??? Or where they would

> classify it as pre-existing only for a year with no coverage?

>

> I'm guessing my best course of action is to get into some kind of a

> group insurance program......any recommendations on that since I'm

> self-employed???

>

> I'm not ready to rush into surgery......but am now thinking maybe I

> should keep my old Kaiser group plan for a couple of months, just

> long enough to have surgery there, so I can get past being labeled

> having a pre-existing condition. But then, I'm not sure that

> surgery would do that for me???

>

> Any help/recommendations/thoughts would be appreciated.

>

> Thanks.

>

> Lucinda