Pre-Existing Condition

System

I'd love to hear how you all would handle this. We have an employee who recently broke a bone in his arm - on his own time, not work related. He and his dad, also an employee, have told us that he had broken that same bone a few years ago but didn't seek medical attention. His doctor told him he had a "malunion" of that bone when he got hurt a week or so ago. Now he is needing an orthopaedic specialist and physical therapy, not to mention surgery, to correct the malunion. We're self insured. Man. If the doctor does not note that the original break was the problem because it didn't heal properly, isn't this a pre-existing condition? Can we ask this of the doctor or inquire about it throug our insurance provider? I don't think we are responsible here, but I'm not sure who we may speak with.

Whatever

You have to read your policy and what it says about pre-existing condition.

Don D

I don't think this would meet a 'pre-existing' definition for insurance purposes. Typically that relates to a condition one had during a period prior to being employed with you and only as allowed under HIPAA regulations. HIPAA was born to make conditions portable and covered from one policy to another. I think you're whistling up a tree on this one.

System

Actually the guy hurt himself the first time prior to his employment here. I'm not even sure he was working anywhere then. Thanks for the input - we'll see what the doctor says.

smaces_twin

Pre-existing conditions only apply if there is a lapse in insurance coverage and generally only last a year. If he didn't have a lapse in coverage it is a non issue. I would not get involved in determining if something is pre-existing and I definately would not talk to the doctor about it. That is what I pay my TPA to do. If he appeals i would get involved, but other than that I would stay out of it.

E Wart

I agree with the others. I think you don't have a chance here. First, how long has the employee been employed and how long is the pre-x condition clause in your plan and does the employee have a HIPAA certification when he came to work. If any of these apply/been waived, then just forget it. If his "pre-x" still applies, talk with TPA about the definition of what a pre-x is, tell them about this occurrence, and let them handle it. We are self insured and I know how it hurts to have these bills. However, as an employee, I will say that this is why we pay for insurance. (Sounds like he had another occurrence/accident which caused the "second break" and may not have had anything to do with the original.)
E Wart