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Home | Preexisting Conditions

Preexisting Conditions

Case Study: Appealing Insurance Claims Denied on the Grounds of a Preexisting Condition

The Problem:  An Insurance Company denied a hospital's claim based on policy language excluding coverage for pre-existing conditions. Upon request, the patient provided a copy of his policy and it was determined that pre-existing condition was defined as "any condition treated prior to the effective date of coverage." Appeal Solutions' first step on any pre-existing denial is to verify the exact wording of the pre-existing clause.

The Solution:
  Careful review of the patient medical records prior to hospitalization revealed that the patient was seen by a physician just days before the effective date of coverage. This, of course, was an immediate red flag to the insurance examiner. The physician records were obtained with the permission of the patient. The records indicated that the initial physician who saw this patient was unable to reach a conclusive diagnosis and referred the patient to a specialist. The insurance coverage became effective after this initial consultation but before a correct diagnosis was made by a specialist.

Legal research for a similar case revealed a decision favorable to the provider's appeal. In Scarborough v. Aetna Life Insurance Company, 572 S.W. 2d 282, the Supreme Court of Texas ruled that medical care and treatment can encompass a preliminary examination. However, for the preexisting exclusion to apply, it is necessary that the insured received a medical service for a known condition. In this situation, I successfully argued that this patient's treatment prior to the policy effective date was for an unknown condition. Therefore, the treatment, if any, rendered prior to the policy effective date was for a different condition and did not bring it under the preexisting definition as defined by the policy.

The Insurance Company released benefits within 10 days of reviewing appeal letter citing this case law.

Potential application for Your Medical Facility:

The condition this patient suffered was parathrodism, often difficult to diagnose. However, with many other conditions, such as athereosclorosis, asthma and mental disorders, the early diagnosis is also often difficult to make and subject to change. Each patient may progress through many stages of these conditions. Cardic patients may initially be diagnosed with heart palpatations or chest and arm pain in early stages of the disease. Angina is often another precursor to atherosclerosis. The point of the Scarborough case is that the treatment prior to the effective date must be for a known condition and the same condition which is currently being denied. In any pre-existing denial, we carefully review the medical records to see if the diagnoses are the exact same before and after the effective date. If not, the provider has an excellent appeal position. can assist providers implement an effective denial management program. is an interactive resource provided to level the playing field between Insurance Companies and Medical Providers. You will find appeal letters, case studies, articles, other resources and the latest intelligence necessary to help healthcare providers make vital decisions and take strategic actions to address payer denial issues. will help health care providers actively develop the processes, analytical tracking information, educational programs and procedures needed for implementing an effective denial management program.

Some of the topics covered at include addressing payment reductions such as usual and customary and out-of-network care reductions, lack of timely filing denials, pre-existing conditions and medical necessity appeals and improving verification of benefits procedures. Treatment exclusions, maximum benefits denials and subrogation/coordination denials are also discussed. Tips are also provided on appealing for interest and penalty payment on late payments and appealing a request for a refund of previously paid claims. discusses all types of claims including Managed Care, Indemnity, Government, Self-Funded, ERISA claim issues and managed care contractual payment discrepancies.

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