Medibank Private and their "pre-existing" condition policy?

[Mahjong]

Anyone had this issue pop up when making a claim?

I was admitted to hospital on Good Friday for Viral Menigitius...

We joined Medibank Private in November. The 2 month waiting period ended in Jan, but we still have the 12 month "pre-exsiting condition" wait out for ANY type of surgery, meaning, we have to get forms signed by Dr's stating we haven't had conditions before joining if something arises.

Ive just gone to claim some costs back, only to be advised that they may not pay for the hospital stay as yet as they may deem it a pre-existing condition :mad: They may pay the claim if they deem it to be legit after looking at the hospital admission forms, if not, Im down $900 :hissy: For something that is caused by a VIRUS :confused: How on earth can that be pre-existing?

Ive been told that I'll most likely have to get all these forms signed by Dr's to prove that it wasn't pre-existing, meaning I'll be down even MORE money to prove to them, to get money back :thumbsdown:

A VIRUS deemed a pre-existing condition? :confused: We're paying $100 a month, just for them to balk at claims and get us to run around chasing forms and signatures from Dr's. If they dont pay up, we're pulling the insurance and thinking of just putting that $100 in a high interest account and using it when we need it the most.

Anyone else had this issue? What was the outcome?

[TeenyT]

When did the symptoms start appearing? I cant imagine you have been walking around with diagnosed Viral meningitis since November (or at least I hope you havent!) therefore how can it be pre-existing? This is why I hate private insurers with a passion!

We were refused cover for our daughter's adenotonsillectomy because she'd been having treatment for recurrent infections prior to joining the health fund. Didnt argue, we just went public and had great service. So often, private insurers will try everything and anything they can to get out of paying large claims in the hope that it will be all too hard and you'll end up not pursuing it. You shouldn't have to pay for a consult for a doctor to sign the non-prexisting form though. And if you do, lodge it as part of your claim!

[*Cj*]

My aunty found that out the hard way. She end up being out of pocket $5000 because of it.:no:

[Mahjong]

It came in Thursday afternoon (admitted Friday) so how on earth they deem it to be pre-exsiting I'll never know :mad:

The woman behind the counter then tried to make it out to be my fault I got the illness by stating I MUST be run down to get it :mad: Little does she know it's caused by a common cold, which ANYONE picks up :rolleyes: I explained to her that I have a Preschooler, she shut up pretty quick then :laughing:

[c38]

Sounds to me like you had a grumpy clerical person who has no idea what she's talking about, and or no people skills. Like you said, it's caused by a virus so theres no way it can be deemed as pre-exisiting. Unless, I guess you have some sort of underlying immunocomromise condition. Ven then that would be stretching it.
I think it's pretty common/standard for them to "investigate" any admission. We get the forms at work for Drs to sign all the time. The Dr shouldn't charge you for doing so.

[Mahjong]

Thank you :D We'll be fighting it if they decide to decline the claim that's for sure!

[RedPanda]

That's ridiculous! I have never heard of a virus being "pre-existing". I agree that you must have got a grumpy cow on the phone.

Good luck with the claim - I think you'll be right once you take it to a higher level.

Btw, that's a really terrific premium price. Do you mind if I ask which level cover you have? I pay $250 per month with Medibank Private.

[Mahjong]

First Choice Saver Hospital, BUT, I think it's no longer available and they have upgraded that premuim to something else?

It's just basic hospital cover only, no extras. We originally sought it after a rough trot with DS1 after his tonsils were removed ($4000 later! We didn't have PHI back then) and we wanted a back up to have in case the kids got hurt, but Ive used it more :laughing:

[zenifa]

I haven't had your experience - I do have a pre-existing condition, and I didn't have treatment and surgery for it, until we'd been paying premiums for over 2yrs and they did pay up (no way I was going to be out of pocket for $50K).

However, when my DH had a vasectomy, we rang Medibank Private to find out if we could claim anything back and there is an issue as to whether you can claim for 'day surgery' or not etc. Won't bore you with too much detail, but one person we spoke to said yes you can claim, another said no and on it went like this.

Anyway DH had the procedure and sent away the relevant forms but had to fight to get his claim processed to his satisfaction (we were in the right all along and he could claim, they were just being a pain and trying to use a loop hole to get out of it).

He got the claim after months of fighting it, and then switched funds in protest (and made sure all the relevant top level people in the fund knew of the reasons).

In short, my advice is - to fight this claim and use the Ombudsmen if necessary.

Also look at using a private health insurance broker to get yourself the best deal you can - we did and are saving $75/mth on premiums ($900/yr) so we are very happy to have left Medibank Private!

Good luck and hope you are feeling better!

[Mahjong]

Thank you Zenifa!

It;s funny you mention that "one person says Yay, another says Nay" becuase I had the EXACT problem with stomach ulcer investigation. One rep said yep, I booked it, only to have them come back when it was all booked, forms signed and ready to go and say "Nay" it's a pre-existing condition as I have had reflux in the past (even though I TOLD them my medical history prior to booking the procedure) :mad: I would have been out of pocket $1000, which like most people these days, dont have that growing on the money tree in the back yard :no:

I also have a few issues (Gyno stuff) which started AFTER we signed up and it's not related to anything in the past, but I just KNOW that it's going to be an issue :mad: Im either going to have to wait for surgery till November, I just hope my hemoragging periods dont flare up until then :fingerscrossed:

The 12 months is up in November.

I'll be definately fighting this one if they say "Nay" Then be pulling the policy with them :yes:

[Crazydaze]

The problem of one person saying yes and another saying no is because the staff you speak to have no claims experience. I've worked for health funds before and the phone staff and branch staff have no actual experience with hospital claims, only the one department who process them, but they dont take calls. Sux really. So if ever I have a claim now I refuse to take a branch staff or call centre staff's word for anything and ask for a call back from the claims manager. They try talk you out of it, but I push hard LOL.

Also if you call them for anything in advance and ask for a written quote, they must do one for you, AND if they stuff up and say you can claim and you will get 'x' amount, but you werent entitled, they HAVE to honour the quote. The quotes are automatically assigned to the policy too so all staff can read them which helps in calls to the call centre if there are problems.

Im with Medibank Private now after switching from MBF. I know that I get a better deal when it comes to out of pockets and the contracts that the hospitals and Dr's have signed with medibank over MBF, even though my premiums were the same. My last proceedure I got quotes from both companies and my out of pockets for MBF (excluding excess & copayment) was $760. My out of pockets with Medibank Private (on the same/equivalent cover) was $125. Needless to say Im glad I am in Medibank Private.

I hope they pay your claim (which they should!). If you dont get any satisfaction, write a letter to the "Conflict Resolution" manager. I filled that role for a few years and I had the power to over rule decisions and grant claims. I 'wrote off' hundreds of thousands of dollars worth of claims each year. Just something to let you know, as most people just write to a manager, and they wont do a thing to be honest. Plus most people dont know there is someone who deals with Conflict Resolution and waivers.

[Mahjong]

Thank you for that! :thumbsup: Will keep that one up my sleeve if the poo hits the fan :laughing:

[Izy]

Funds usually assume anything within the first 12 months is considered pre-existing until they have evidence to prove otherwise.

You should be able to ask the specialist to complete your pre-decision form without a consult. Let them know that their Dr's bill won't be paid without the certificate and they're quite quick to complete it too :p

I agree with front line not knowing about hospital claims but have to disagree on the whole trying to get out of any claim they can idea. If you have a non-exclusionary cover they'll pay any medicare approved procedure after 12months no questions asked.... how is that getting out of every claim imaginable?

[RedPanda]

Izy, off-topic I know, what was your previous name? I'm trying to place you but can't :o

[Mahjong]

The problem is though Izy, I never saw a specialist, just admitted through A&E by the Dr on duty if you know what I mean? Chasing this Dr would be hard as I have no idea when he works :laughing:

They stated that if they want the forms filled out, I'll need to get my regular GP to also sign it, but considering I never saw him for the illness as it was so bad I couldn't see, walk or talk properly, DH took me straight to A&E, being an emergency.

Hopefully they will pay it, being a virus and all. Im just annoyed that the woman at the claims centre assumed it was self inflicted and being "run down" :rolleyes: Anyone catches a virus. :mad: I was unfortunate to get the brain swelling from my body fighting the infection (up until that day, was feeling fine, just a sore head that was progressively worse - which is how it starts)

[Izy]

Bep- get a copy of your emergency admission summary (probably called something different- but the details from your admission) including the section where the Dr asked you about symptoms etc.

Submit that with a cover letter explaining that this was an emergecy admission and you didn't see an individual specialist or GP, and submit it to thier hospital claims dept.

Witchazel- I've always been Izy, I'm too lazy to change names

[Mahjong]

Thanks Izy :thumbsup: I can do that one... hopefully I get word this week if they accept the hospital's claim or not :fingerscrossed: If I get asked for the forms to be signed etc, I will head up to the accounts at A&E and get copies. They would hand them over wouldn't they?

The weird thing too is that I explained that to the woman at the counter that it was through A&E and not a scheduled procedure, but an emergency.. she said it didn't matter, even if it was just routine surgery, I still would have been admitted through A&E :confused: That was a weird thing to say :confused:

[Izy]

As mentioned by a PP the people on the front line really don't deal with hospy claims. And they're taught that procedure needs to be followed without exception.

I know that from where I support front line for another fund (well 4 different funds to be precise) if we tell a consultant they can do something 'special' once and once only, you can be certain they will try to make it standard practice :o So they tend not to be educated with the 'special circumstances'. You'd think that commonsense and discretion would work........