Lean Healthcare - My wife burned herself and that is considered a pre-existing condition.

We just recently got new insurance via Blue Cross Blue Shield of Michigan and discovered that anything that happens to me, my wife K. or daughter D. is considered a pre-existing condition for the next 6 months.

Back Story-

My wife accidentally knelt down on a lighter that had just been used to light the birthday candles on my daughters cake. 

She got a burn that was about the size of my thumb and quickly formed a blister.  The following day it was much redder around the area so we thought we might have to go see the doctor.

We had just changed insurance and were not certain how the new coverage worked.  This prompted a phone call to Blue Cross Blue Shield of Michigan which led to some startling information.

Everything is considered a pre-existing condition until proven otherwise.

"NOTE: All benefits, except preventive services, are subject to a 180-day waiting
period for pre-existing conditions. " 

This is what the top of the brochure says for the health plan.  What isn't mentioned is that anything that happens to you for the first 180 days is automatically considered a pre-existing condition until proven otherwise.  Be careful...if you or your spouse are decapitated you may need to prove that this wasn't a prior issue.

 

You are responsible for paying the doctor's bill and have to wait to get paid back by the insurance company.

Your provider will need to submit paperwork to prove that whatever happened to you is not pre-existing.

Paperwork will need to be filled out by the provider of the service (doctor or hospital) and submitted to Blue Cross Blue Shield for review.  Download BCBS Forms

A trained reviewer will examine the information to determine if this was indeed a valid claim and not a pre-existing condition.  If the claim is approved then you will get paid back.

Time frame for having your claim processed and getting paid back...UNKNOWN.

 

This is so confusing BCBS people are well versed on the subject.

I spoke to a very pleasant woman at BCBS about this at length.  She said that they went through a lot of training about this because it is one of the most confusing and common questions they get.  It seems like they are treating the symptom and not the root cause.  Maybe a less confusing plan would be better or allowing the hospital some discretion about what to consider a pre-existing condition.

In the end we didn't go to the doctor.  By the time we had figured out the insurance,  the wound had begun to heal from the bandage + Neosporin we were using.  I asked the nice BCBS person to e-mail me the forms for future use however they don't have external e-mail.  She had to "snail mail" them to me instead.