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skeeter14

disability policy- pre-existing conditio

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Hi,

Thanks in advance for your time to read my post.

I enrolled in an employer disability policy that became effective 9/1/08.

Submitted a claim after shoulder surgery July 09. I did not consult medical advise until 10/08. BUT, I did report I thought my symptoms (intermittent shoulder pain) started in 6/08 or 7/08 after doing housekeeping activities. Because it is documented in my medical record that I thought symptoms started before the policy became effective, my claim was denied.

My argument is that based on their definition of pre-existing condition. They state it's the existence of symptoms which would cause an ordinarily, prudent perosn to seek medical diagnosis, care or treatment during the 2 years before the effective date.

I am an ordinarily, prudent person and I did not think my symptoms were anything more than just "overdoing it" and that I did not need to consult a doctor for diagnosis at this time. When the symptoms worsened and persisted , then I consulted my doctor in 10/08.

Has any legal precidence been set for this situation? I know it is very subjective, BUT come on. Average, prudent people don't consult their doctors after every onset of aches or pains. Being a thorough person, I reported to my doctors and documented on claim form that the first sign of illness was June 08 when I think it started after a weekend of heavy housekeeping.

I appealed this initial decision on my own and they denied it again based on fact that I had symptoms of a disabling condition before my effective date.

Any input or experience with this ordinarily, prudent person definition?

Thanks,

S

[This post has been edited to remove personal information- Moderator]

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This isn't an employment law issue as such -- it's a matter of a weasly insurance company.

The insurer is doing something very common these days, I'm afraid.

This isn't something you can handle yourself. You need to talk with a local attorney who handles fighting insurance companies on bad faith claims (I presume your company's plan administrator isn't of any use).

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I may be wrong, but I thought that pre-exsisting condition was when you had already received medical attention for that condition, not that you go to a doctor because your shoulder was hurting a little bit and then kept getting worse and worse and you finally get medical attention after you receive medical benefits. If you tell your doctor your shoulder started hurting in the timeline of having insurance, and you never saught medical attention beforhand, I can't see how any insurance company can prove that was pre-exsisting condition, they can't prove you sought medical attention before your eligibility date, so they can't say it was pre-exsisting.

Hope that helps........some

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Insurance companies define a pre-existing condition as anything that may have existed before the policy went into effect. If you had shoulder pain for 2 months before you got the insurance, that's a pre-existing condition as far as they are concerned and they will not pay. Welcome to the health care reform debate.

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