Accidents caused by someone else can be very stressful. This stress gets worse when you worry that your insurance company might reject your claim because of a pre-existing condition.
Sadly, this happens a lot. Insurance companies are businesses. Their goal is to make money and keep it up. So, when they reject your claim because of a pre-existing condition, do not give up. You still have the right to fight for the money you deserve.
In this article, we will explain what a pre-existing condition is. We will also explain why insurance companies use it to reject claims. Then we will show you what legal steps you can take to fight back. We will also explain how to prove your claim. This includes using medical records and something called the aggravation doctrine to get the compensation you deserve.
What is a Pre-existing Condition?
A pre-existing condition is a mental or physical condition that someone had before they sustained a new injury. Typically, an insurance company will attempt to use a pre-existing condition to avoid paying the injured party’s compensation. Examples of pre-existing conditions are:
- Asthma
- Joint problems
- Back problems
- Neck problems
- Knee problems
- Anxiety
- Depression
- PTSD
Should you have a pre-existing condition that you had before your accident occurred at the hands of a third party, you may find that the insurer attempts to deny your compensation claim. Luckily, they cannot refuse to pay compensation due to the existence of your pre-existing condition.
However, they can deny a claim if you seek compensation for an injury you sustained before their insured negligent actions.
What To Do If Your Claim Was Denied Because Of Your Pre-Existing Condition
You do not have to accept the insurance company’s claim of denial. Instead, you can fight the denial by proving that the injury you seek compensation for is not a pre-existing condition, if your pre-existing condition was stable before the events leading to the insurance claim.
And you may be entitled to compensation if you can show that the accident aggravated your prior condition. If the insurance company is not budging on reversing its denial of your claim, you can hire a car injury lawyer and file a lawsuit against the insurance company and the negligent party.
Second, under the ACA, no health insurance company can deny you insurance because of any preexisting conditions you have. The Affordable Care Act (ACA) is an American health care reform law, popularly known as Obamacare, enacted in 2010 to enhance access to affordable health insurance, eliminate preexisting condition exclusion, allow children up to 26 years old to stay on parents’ plan, and provide subsidies to marketplace coverage.
Aggravation Of Your Pre-Existing Condition
If you have a pre-existing condition such as those described above, you are not necessarily disqualified from workers’ compensation, even if the claim is related to that same injury. California workers’ compensation will cover an injury connected to a pre-existing condition if workplace conduct constituted a “new” injury that aggravated the pre-existing condition.
Take, for example, a physical therapist who suffers from arthritis in her lower back. While at work, she attempts to help a patient out of bed, causing a disc in the worker’s back to bulge. As a result of the disc injury, the therapist is unable to work. The bulging disc is a “new” injury, caused by workplace activity, even though it was connected to a pre-existing condition.
California law asks if there was a new injury, whether there is a new need for medical attention, or a change in existing treatment, caused by a new workplace activity. If so, then the injury is called an “aggravation.” The aggravation here would be covered by workers’ compensation.
Recoverable Compensation
Recoverable compensation refers to financial damages and losses an injured party can legally claim from a responsible party in a personal injury case, or to funds recovered by an
If you were injured because of someone else’s carelessness and the injury is not related to your pre-existing condition, or the incident makes worse the pre-existing injury, you may be entitled to the following compensation:
- Medical expenses
- Lost wages
- Lost or reduced capacity to earn
- Pain and suffering
- Property damage
Appealing a Health Insurance Decision Regarding Pre-existing Conditions
In case your health insurance company denies coverage for your pre-existing condition(s), what you have to do first is make a written request for a denial letter, file an internal appeal by the specified deadline (usually 180 days from the decision date), and obtain medical records from other health care providers that show that your condition was not covered during the look-back period. Work with your physician for a letter of medical necessity, and if needed, an external review.
Steps to Fight the Denial
- Ask for Detailed Denial in Writing: Ensure that you get the reason for denial in writing, including the actual policy language or definition of what is a “pre-existing condition.”
- Look Back Period: Verify Your Plan Documents: To find out your look back period (maybe six months before coverage). If a disease is not diagnosed or treated in the look back period, then it won’t be pre-existing.
- Collect Documentation and Evidence: Collect all related documentation, test results, and physician’s notes.
- Get a Letter of Medical Necessity: Request a letter from your doctor outlining the reasons why the treatment is medically necessary and explaining why the treatment is not subject to exclusion due to pre-existing conditions because symptoms were not there before coverage.
- Initiate an Internal Appeal: Request the insurance companies to reconsider their decision and provide supporting documentation.
- Ask for an Expedited Review: If your life or health is in danger, then you may request the insurers to conduct an expedited review. It must be done in 72 hours.
Tips for Success
- Be Persistent: Don’t be discouraged by the initial denial because most claims get approved on review.
- Maintain Documentation: Always keep a log of your calls with the insurer and make sure you note the dates and who you speak to.
- Verify Accuracy: Make sure that your claim hasn’t been denied because of an error in the coding process or billing.
Conclusion
This pre-existing condition does not mean that you have to be denied. Most insurance companies have an excuse in this manner to refuse the claim that should be accepted, but through the appropriate evidence and sound appeal, you can be accepted. Do not let your denial stand.
If your personal injury case has been denied, you don’t have to handle the situation by yourself. The legal team at Cockayne Law will be happy to assist you throughout the entire process and ensure that you receive maximum compensation for your injuries.
Frequently Asked Questions
Q1. How do you prove the aggravation of a pre-existing condition?
Under CACI 3928, Aggravation of Pre-existing Condition, juries are told to award damages for the extent to which the accident worsened an existing condition. Any increased pain, disability, or medical care required. The lasting effects of aggravation.
Q2. What are some examples of pre-existing conditions?
Some examples of pre-existing conditions can include diabetes, COPD, cancer, and sleep apnea. They usually tend to have chronic diseases.
Q3: How do insurance companies verify pre-existing conditions?
Insurers constantly identify pre-existing conditions for everyone by checking their medical record, which include all their visits to doctors, prescription medicines, and diagnoses made up to a particular point in time known as the “look-back period.” Pre-existing illnesses such as diabetes and cancer, among others, can be determined from the records, helping insurers assess risk despite what the ACA dictates in the USA.
Q4. What is the average payout for personal injury?
There’s no true “average” payout because every case is different. The amount depends on the type of injury, how severe it is, how long recovery takes, and the financial impact on your life
Q5. What are the two main reasons for denying a claim?
The two main reasons for insurance claim denials are policy exclusions (lack of coverage) and incomplete/inaccurate documentation. These stem from either the event not being covered by the contract or failure to provide sufficient proof of loss to the insurer.
