[mcanvasback]

I applied for med. insurance for Bella in November, I was going to do the BC/BS HMO, which could not begin until she was one, then the rates went up so much I decided on the PPO. So, sent in the app with the medical records that I had from previous out of pocket doctor visits. In the records the doc had recommended that I take her to an opthamologist to rule out strabismus, (some type of "lazy eye")

So, I get the approval back with an exclusion rider saying that any expense, anytime, tests, doc visits, surgeries, from strabismus will not be paid.

Can they do this? She has not even been diagnosed with it, this would have been a precautionary visit!

Any advice on what I should do?

This is Blue Cross/Blue Shield of Florida Blue Options and it's the best coverage I found for the price.

Thanks for any help!

[kimber413]

First, get your policy out and read the fine print about the vision coverage. They may only pay for routine eye exams and glasses. You could then take her to an optometrist instead of an ophthalmologist for the diagnosis. If it's simply a glasses or eye patch prescription to strengthen the muscles in the wandering eye, he can do that and it should be covered. If you really want to see an ophthalmologist, look and see what you have to have for a referral to a specialist, and what is covered there. If all of this looks like strabismus should be covered, I would call them up and talk to them personally. They may not know the situation, as far as the adoption and such goes. If you get guff from the first person you talk to, ask for the departmental manager.

[crispex]

I'm not certain how individual policies work, but employer based "group plans" have to take the child as if she was a birth child. The stipulation there is that you have to get her signed up within 30 days of the adoption being finalized. After that, they can exclude "preexisting conditions."

[Kasey]

Crispex is correct, if your insurance is through your company or employer then the child is generally covered for all immediately (just like if you gave birth), but for private individuals plans they can have preexisting clauses. My BIL and SIL have dealt with this several times since he is self employed, SIL and one of my nieces have othropedic injuries from the past that could be chronic and it always stipulates they are not covered for those.

[pequele]

no if you didn't sign up/add on your child to your policy within X number of days of birth or adoption (per your plan) pre-exisitng conditions CAN be excluded. Also, any private plan CAN exclude ANYTHING they want when applying for new coverage. My plan (through work) has to have the child signed up within 30 days of adoption or he/she will be considered a NEW applicant and exclusion can occur.

[Amysue1112]

Sadly, with a private plan, they can do what they please. A few years back, my sister had vag bleeding for a long period of time...it finally stopped with short term meds, but they never really diagnosed anything and no more problems.
Recently, they signed with a new insurance plan..b/c of this issue, there was a ryder that said they would not cover ANYTHING that had anything to do with ANY gyn issues...NOTHING. It is stupid, since they pay more for her than the rest of the family combined, but that is private plan.

But from what I know, group plans can't do this. You know I have had lots and lots of surgeries with all sorts of med issues and have never once been told I was not covered from prexisting conditions..

Is this a plan with your job? Can you get one with them?

If you really have no option...fyi, you can take a class at a university or junior college and can get med insurance (group plan) with them...I know you have no time for that but it is good for others to know and nice to know if you can't find another way to get a good group plan.

Many insurance companies don't even include eyes...unless it is major surgery...so maybe you could get her eyes checked out and if they are ok it won't be a problem....but I am still leary of private plans..they can make new "rules" as they choose, and you don't have a "group" plan to back you up.

[Ktates]

Mel - I have blue cross blue shield (ppo) - they do cover the strabismus but it is billed as medical not a vision issue (since not correcting it could lead her to be blind). I would call them up and find out what the story is...best of luck

Edited to add - ask the office staff where you will be taking Bella - they may know how to bill it so it's covered...

[SingleMama2B]

Hi Mel.... Yes, as other's have said.... if it is a personal plan and not through your employer, they unfortunately can and most cases will exclude "pre-exsisting" conditions (even is written as a possibility in her records). I had to put m DD on my policy at work even before I went to court due to the fact of the biling cycle. If I hadn't, she would have traveled home and it would be like 10 additional days before I could add her.

I would talk to a supervisor at the plan you signed up for, and explain the whole situation, etc. (adoption, etc.), and see if there is anything that can be done to have NO exclusions..... Good Luck!

[votemom]

it's possible (?) this is not an issue of an adopted child, but just an issue of how much they'll cover when it comes to a certain medical issue.....?

drag out the manuals and put on your readers!


sorry for all the frustration.

[sak9645]

First off, do you have group insurance through an employer with more than two covered people? Or do you have an individual policy?

If you have group insurance, then the Health Care Portability and Accountability Act (HIPAA) applies.

Under HIPAA, if you have a policy that would normally cover biological children, that coverage MUST be extended to an adopted child, as of the date that he/she was either adopted or PLACED with you for adoption. There can be no exclusions or waiting periods for pre-existing conditions, and no waiting periods for enrollment.

HOWEVER, to take advantage of the HIPAA protections, you MUST provide information, in writing, to your employer/insuror WITHIN 30 DAYS of the adoption or placement for adoption. If you fail to do this, HIPAA does not apply, and you could be subject to any exclusions or waiting periods for enrollment or coverage of pre-existing conditions.

In short, if you had a group policy with the PPO prior to your adoption, you should have enrolled your daughter in it within 30 days of the time the judge finalized your adoption in Russia. In that case, the PPO would have had to provide coverage, retroactive to the date the judge finalized the adoption, for any normally covered medical service, whether or not there was a pre-existing condition.

In your case, however, assuming that you had group insurance, you were NOT a member of the PPO prior to your adoption. Therefore, you could not add your child to your PPO policy within 30 days of the adoption. Thus, HIPAA does not apply to you, and the insuror can set any rules regarding pre-existing conditions that it normally applies to other customers like you.

If you do not have group insurance, then HIPAA doesn't apply at all. A few STATES have laws similar to HIPAA, and say that people with individual policies can add a newly adopted child to their policy without exclusions or wait periods. However, these laws will also assume that you are already have coverage under that insurance plan and that you notify your insuror within a short period of time after your adoption.

Unfortunately, these laws would not apply to you, either, since you were not a member of the PPO at the time you adopted.

I really wish that homestudy agencies would discuss health insurance with families as part of the homestudy process. It is terrible when a person assumes that his/her child will be covered, and then finds that HIPAA does not apply or that he/she has not complied with the rules regarding adding the child to his/her policy within 30 days of adoption or placement for adoption.

Sharon

[mcanvasback]

Thanks to everyone who responded and yes it's a private plan, I'm a Realtor so have no group insurance.

I will start by taking her to the opthamologist to see if she even has an issue, then decide what to do depending what they tell me. I would be out of pocket anyway since there is a deductible for specialists. If shehas it, I will ask there advice and I guess start the battle with BC/BS> IN the meantime, if I don't sign the exclusion rider, she has no insurance! Sigh.

[1moretime]

I can tell you from my own experience with my child who also has strabismus. I called my BC/BS in MD insurance. They said as long as I added him to my plan in 30 days he was covered. I started at the opthamologist, wasn't trilled with the office. Took him to see my optometrist who is treating him esp since he doesn't need surgery and he is doing fine. At 8 he began wearing contacts and it has helped. By the way he was 7 at time of adoption. Because he is older, his may never be completely corrected but he has made improvement. Fight with the insurance.

Nancy

[hml1976]

I'm sorry this happened to you. Believe it or not our daughter (who is healthy as a horse) was denied altogether by Assurant when we first arrived home. They wanted to wait and make sure that she didn't have any unforseen issues arise as an international adoptee. I was livid and refuse to work with them. Luckily the company my husband was doing contract work for agreed to make him an employee so we could have coverage. It still makes me want to spit fire just thinking about it!