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Do you have a pre-existing condition when you sign up for a medical insurance company for the first time?

My husband signed up for Blue cross blue shield ppo for the first time ever-He never had insurance before. He was told by Blue cross blue shield he will have one until he goes to the doctor and he says he doesn't since this is a new file or something like that. He went one day for the first time ever in his life to the eye doctor under the vision insurance also new never had one -for a vision test to see if he needs glasses. They told him he has pterysium and has to go to a specialist to get it removed. He went referred and asked if they can check if he will be covered they said yes but only under the medical insurance Blue cross...They said that the insurance said he has a pre-existing condition and he should call to find out what it is... Its controversial the lady at the insurance company says you get pre-existing condition until the doctor proves it wrong. Then says but he doesn't have a pre-existing condition. Maybe we are not understanding this right is there anyone who knows or can explain it to us please?

Public Comments

1. It depends on the medical insurance plan on whether or not your husband is subject to a pre-existing limitation clause. The insurance company should be able to answer this question for you but you talked to someone at the insurance company and you didn't get an answer to your question. Generally, when you have insurance for the first time, you are subject to a pre-existing conditions clause. A typical clause would be: If you had the medical condition or you had treatment for it, before you became insured then the insurance company won't pay for the cost of treating the condition until you have been insured with them for 12 months (or sometimes actively working for your employer for 6 months). So, specific in your situation, I think the woman at the insurance company is referring to is when people know they have a health problem and don't seek medical treatment and enroll in a health plan and then go get treatment. In order words, they try to cheat the insurance company into paying for their medical treatment and might not have enrolled if they didn't already know they had a health problem. If the treatment for your husband's condition is expensive, I would call your insurance company (and try to talk to some besides the woman you talk to before) and ask if you could have your husband's treatment pre-certified. That would mean the eye doctor would submit the plan of treatment and the insurance company would review your husband's eligibility and whether or not they will pay for his treatment. I know it is difficult to trying work with insurance companies. In this situation I would look at what is most important. Does your husband need treatment for the pterysium immediately or his vision might be impaired or he even may go blind? In that case, I would talk to the eye doctor and tell him you don't know what the insurance company will pay but would he perform the treatment and help you work out a payment agreement - your insurance company might still pay for the treatment but you are putting your husband's vision before money. Good luck. I wish you and your husband the best.
2. A pre-existing condition is one that you have been treated for or at least had diagnosed BEFORE your insurance policy began. Most insurance policies will even cover those after a certain period of time i.e. a year, but if it has just been discovered and you have never been treated for it or it was never diagnosed before, then it is not pre-existing.
3. If he had the pterysium before he had the insurance, it IS a pre-existing condition. "you get preexisting condition until doctor proves it wrong" is NOT correct. The doctor would have to say, though, that the pterysium did NOT exist before the policy started, for it to be covered.