Pre existing waiting period in BCBSIL

[random31]

My husband got his policy with BCBSIL early June of this year. In the middle of October we found out that he has Hep C. He is on induvidual plan. Our GI doctor gave us prescription for Pegintron and Rebetol. We went to a regular Walgreens to get it and found out that our insurance is not going to cover the costs. Called ins., they told us we have to go thru a specialty pharmacy. Specialty pharmacy also told us they canot mail the medication to us becuase there is a pre exsiting waiting period on his policy. Called ins. again, they keep denying the coverage over the phone. What should we do in this case? We did not know about this illness until October. Do they have a right to deny? Is there a way around this? File a complaint/ appeal? Get medication somewhere else? Please help.

[Trinity4]

Since his coverage was effective in June it appears they are putting a 1 year pre-existing  condition exclusion or a waiting period; they won’t cover a medical expense associated with that condition for an extended period of time.   However, he had no diagnosis of his condition even though it is considered a chronic illness.  I have dealt primarily with group health coverage, not private so I don't know exactly what they can get away with.  I highly advise you read your policy and see what it says about coverage for conditions diagnosed after the effective date of the policy.  

Also, if you can't find anything in the policy that indicates you must wait a year for coverage call BCBS and ask them to give you the specific clause or paragraph in your policy that denies coverage for one year.  Don't let them intimidate you, stay on their
a-s-s until you get answers.  If they can't provide the information you are seeking, tell them your attorney will be in touch.  

Trinity

[random31]

"clause which states pre-existing chronic illness will not be covered until a certain amount of time has passed".... they are telling us to wait until june of 2011. And he probably had that illness before we got the insurance... but we didn't know about it. There are no records to prove othervise. Does that make any difference?

[fretboard]

My guess is some insurance companies don't appreciate the expense of the meds and may require that certain steps be followed prior to authorizing patients to start SOC for HepC.  Could be that your husband has gone to far ahead of the Insurance company in the sense of evaluation.  Has he had all pre-tx reviews, like the liver panel blood tests, the ultrasound and the liver biopsy?  If you haven't had those things done then maybe those items can block the tx authorization process.  just a thought!  If your husband has already has every test known to mankind then forget my post and good luck!

[nygirl7]

Fortunately in most cases HCV is a slowly progressing disease - I don't know what stage liver damage he has but it's quite possible it wont make a difference if you wait a few months or not?

[Trinity4]

If your husband has never been diagnosed with hepc and there is no record with any doctor or hospital of him having hepc or was treated for any hepc related illness and I mean the diagnosis specifically states due to hepc they can't deny him coverage.  With it being a private policy there may be clause which states pre-existing chronic illness will not be covered until a certain amount of time has passed.  Insurance companies are notorious for clauses and small print.  

Appeal it.  You can involve your congressman and the Illinois State Department of Insurance.  

Good Luck,
Trinity