This is in response to your recent inquiry on behalf of Ms....
[redacted]. Please be aware that this response may contain personal health information on the claimant. We trust the Department will only make this information available to those persons authorized to receive it. Ms. [redacted] purchased international travel coverage under our StudentSecure group travel insurance policy issued to the Atlas/International Citizens Group Insurance Trust, Hamilton Bermuda. Ms. [redacted] is a citizen and resident of China. The insurance is underwritten by Lloyds Syndicate 4141 and HCC Medical Insurance Services (HCC MIS) is the Coverholder and Administrator. After review of the information on file, it has been determined that we have sufficient information form Ms. [redacted] to complete processing the claims on file. The claims have been approved and an updated explanation of benefits will be sent to Ms. [redacted] directly within 10 business days.I hope this information will allow the Bureau to conclude the handling of this file. If I can be of any further assistance, please let me know. Sincerely, Lori L[redacted] Paralegal and Complaint Coordinator
I have reviewed Mr. [redacted]'s file. The application required underwriting and was approved on January 11, 2016. A cancellation request was received on January 13, 2016 and processed the same day. At that time, the premiums were refunded to Mr. [redacted].If I can be of further assistance, please let me...
know.Respectfully, Lori L[redacted]ParalegalHCC Life Insurance Company317/[email protected]
I have provided Ms. [redacted] with my direct number to reach me in the future. HCC Life Insurance Company has received the authorization completed by Ms. [redacted] and forwarded it to the facility to release the requested medical records. Once medical records are returned, we will continue our review.If I can be of further assistance, please let me know. Respectfully, Lori LongParalegalHCC Life Insurance Company317/221-8013
We apologize for the delay in processing Mr. [redacted] claims. We are currently waiting for medical records from his provider's to determine our liability. Once these records are received, we can continue our processing.
I hope this information will allow the Bureau to conclude the handling of this...
file. If I can be of further assistance, please let me know.
Respectfully,
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that the response would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
Have all the records for my claims been requested so that they can be reviewed? If not, which records still need to be requested? Have any of my claims been reviewed yet? If so, what is the status?
Regards,
[redacted]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID 11492964, and have determined that the response would not resolve...
my complaint. For your reference, details of the offer I reviewed appear below.This company is attempting to say that every single claim I've had is a result of my hearing loss (which I've had since I was born), and therefore not covered. The issue that brought me into the doctor's office in the first place was headache and neck pain. Because I do have hearing loss (even though unrelated), my doctor put hearing loss as one of my diagnoses. It is UNRELATED to the headache/neck pain that brought me into the office. It is like saying someone's broken foot is a result of their hearing loss. Ridiculous. The first doctor I visited ordered an MRI and CT, an eye exam and blood work. He wanted to rule out any growths/tumors, etc. the MRI came back saying I have Chiari Malformation. Following these results, the doctor sent me to a neurologist and a neurosurgeon. The neurosurgeon ordered another MRI (a different type) and the neurologist did some additional blood work. They did these to best decide how to treat me and my headaches and the Chiari. HCC has chosen to deny all of these claims - the doctor visits, the blood work, every scan. They are still attempting to say 'condition not covered'. First of all, we didn't even know what condition it was at first - which was the reason for the tests. Second of all, it has nothing to do with my hearing loss. I have called multiple times and e-mailed and explained this. I filed my appeal in February and they had chosen to ignore it - until now after I filed an complaint. Now they are asking for records and saying they will review my appeal. I know I'm not the only person they are doing this to - I've read the other complaints. I have one guy who has contacted me a few times since filing the complaint and he acts like he actually wants to help. So I will send them my records, but I'm not holding my breath. The neurosurgeon wants to do surgery to alleviate the now daily neck/head pain I have. However, I can't even consider it until I am able to add to my husband's insurance and drop HCC. I've already racked up almost $20k in bills that are being denied. Lord knows how much this surgery would cost.
Regards,
Samantha Dyer
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that the response would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
Regards,
[redacted]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that the response would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
I find the response by HCC quite confusing. I am not sure what they mean when they say "HCC does not
hold any contracts with the provider. The contract is between the network and the provider". All I know is that I checked HCC website to see which facilities were considered in network, and I went to a facility that was listed as "In network" on their website. They also say "Mr. [redacted]’s policy
does not guarantee an innetwork provider. " If this is true they should provide documentation that my policy holds me responsible for an out of network provider even if I went to a facility that was within network and saw a provider of which I did not have a choice. They again have said " it has been determined that the claim on file has processed correctly." However, if this was the case from the very start, then why did they try negotiating for a discount? They must have known that something was amiss with this situation. As I stated in a previous response, the billing office for the emergency physician group said that charges for a visit are the same, but the patient financial responsibility depends on how the insurance processes it, whether it is considered in network or out of network. My argument from the start is that if I went to an facility considered in network by HCC and saw a provider who I had no choice, then I should be responsible for the in network charges regardless of how the provider shows up in HCC's system.Again, as I have said in the previous response, I am happy to file a complaint with [redacted] Hospital or the [redacted] group if HCC thinks the burden lies with them.
Regards,
[redacted]
Revdex.com:
I would like to find out when should I expect the reimbursement payment mail to my address? Could you ask them? Thank you.
Regards,
[redacted]
Please see the attached response to the following complaint: RE: Policy Administrator: Tokio Marine HCC Medical Insurance Services GroupRevdex.com ID number: [redacted]Complainant: Mr. [redacted]Insured: Mr. [redacted]November 3, 2016 Ms. [redacted] Revdex.com Serving Central Indiana 151 N Delaware Street #2020 Indianapolis, IN 46204-2599 RE: Policy Administrator: Tokio Marine HCC Medical Insurance Services Group Revdex.com ID number: [redacted] Complainant: Mr. [redacted] Insured: Mr. [redacted] Dear Ms. [redacted]: This is in response to your recent inquiry follow up on behalf of Mr. [redacted]. Please be aware that this response may contain personal health information on the claimant. We trust the Bureau will only make this information available to those persons authorized to receive it. While we understand that Mr. [redacted] is unhappy with the processing of the claim in question, HCC does not hold any contracts with the provider. The contract is between the network and the provider. Mr. [redacted]’s policy does not guarantee an innetwork provider. As stated in our previous response, HCC reached out to the provider in attempt to negotiate a discount and was unable to do so. We have again reviewed the file and it has been determined that the claim on file has processed correctly. If you need additional information, please let me know. Sincerely, Lori L[redacted] Paralegal and Complaints Coordinator Tokio Marine HCC Medical Insurance Services Group 317/221-8013 ll[redacted]@tmhcc.com
We have reviewed Mr. [redacted] file. It appears we are still waiting to receive medical records from Mr. [redacted] physician. Once we receive this information, we can continue our investigation. If...
you have any questions or concerns please let us know.Respectfully, [redacted]Compliance [email protected]
Regarding #1, the insured must complete the attached form and submitted. This must be completed and signed by the insured, MR. [redacted]. [redacted] cannot complete it on the insured behalf.Regarding #2, even though the claims were appropriately denied, HCCMIS will make an exception to allow the following claims as eligible in a good faith effort to resolve this issue. New EOBs will be mailed once the claims are reprocessed:[redacted] Sincerely, Jon P[redacted]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that the response would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
Hi,Thanks for taking steps to resolve issues related to insurance claim for Mr and Mrs [redacted]. However, there are few issues still need to resolved.Let me again divide my response in two parts.1) Mr [redacted])I’m satisfied with the resolution for all the claims provided by HCC Travel Insurance. However, Below is the request to adjust deductibles.Claim # [redacted] (198 USD) - Since this claim is already paid by me. Request you to pls adjust this amount in deductibles, If you want to issue cheque, Pls issue in the name of [redacted]. (Son of [redacted]).Claim # [redacted]- I agree that this claim is not covered under insurance policy and I’ll take care of the payment for this claim.I hope my request will be consider by HCC. 2) Mrs. [redacted])I’m attaching the claimant statement, submitted on 10/02/2015, where I clearly states that first onset of the condition is on 06/24/2015.Let me brief with situation.Mrs [redacted] felt mild pain in the night of 06/24/2015 during toilet and this pain was worsened in the morning of 06/25/2015. Hence, we immediately consulted Dr. [redacted] on 06/25/2015 itself. So, I believe this onset was well within the 24 hours.I hope above explanation and attached claimant statement will satisfy HCC and kindly urge you to process all the claims related to Mrs [redacted].Regards,
[redacted]
Regarding Mr.
[redacted]’s pharmacy claim ($198.00), this will be entered and processed. The claim number for this new claim is: [redacted].In regards to coinsurance for Mr. [redacted], the coinsurance was
waived. However, Mr. [redacted] is still
responsible for the $500 deductible. Below are how the claims will be processed with deductible:Claim # [redacted] - 59.40 towards the
deductible- no coinsurance taken Claim # [redacted] - $440.60 towards the deductible- no coinsurance
taken Claim # [redacted] - no deductible taken and no coinsurance taken.In regards to Ms. [redacted], these claims relate to a
procedure for a condition that occurred prior the issuance of the policy. The policy does have an acute onset of pre-existing
conditions benefit. However, treatment
must be obtained within 24 hours of the sudden and unexpected outbreak or
recurrence. Per the claim form, the
condition first began in the 3rd week of June. Since this Ms. [redacted] received treatment on 6/25/15, this would be
over the 24 hour requirement. Thus, the
claims were correctly denied as pre-existing.
Mr. [redacted] purchased international travel coverage under our Atlas America Program. The Group Master Policy is issued to the Atlas/International Citizens Group Insurance Trust, Hamilton Bermuda. This insurance is underwritten by Lloyds, London and HCC Medical Insurance Services (HCCMIS) is the...
Coverholder and Administrator.
Mr. [redacted], a citizen of India, purchased coverage with an effective date of 5/11/2014 and termination date of 5/28/2014 for his travel outside India including the United States.
HCCMIS has previously received and responded to a Pennsylvania Department of Insurance complaint from Mr. [redacted] regarding his claims denial. As explained in the Department of Insurance response, Mr. [redacted]'s was treated on 5/19/2014 and had surgery the same day. Per the medical records, the symptoms started one month prior. Based on this, Mr. [redacted]'s condition would be considered a preexisting condition under the policy. Please see the below definition and exclusions.
Exclusions:
42. Pre-existing Conditions — Charges resulting directly or indirectly from any Pre-existing Condition, as herein defined, are excluded from this insurance, except charges resulting directly from an Acute Onset of Pre-existing Condition, as herein defined, are covered for all Members subject to the limits set forth in the Schedule of Benefits and Limits.
Definitions:
Pre-existing Condition: Any (1) condition for which medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) was recommended or received during the 2 years immediately preceding the Certificate Effective Date; (2) condition that had manifested itself in such a manner that would have caused a reasonably prudent person to seek medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) within the 2 years immediately preceding the Certificate Effective Date; (3) injury, illness, sickness, disease, or other physical, medical, mental, or nervous conditions, disorder or ailment (whether known or unknown) that, with reasonable medical certainty, existed at the time of application or within the 2 years immediately preceding the Certificate Effective Date. For the purposes of the Complications of Pregnancy coverage offered hereunder, Pregnancy will not be included within the definition of a Preexisting Condition.
Acute Onset of Pre-existing Condition: The term "Acute Onset of a Pre-Existing Condition(s)" shall mean a sudden and unexpected outbreak or recurrence of a Pre-existing Condition(s) which occurs spontaneously and without advance warning either in the form of Physician recommendations or symptoms, is of short duration, is rapidly progressive, and requires urgent care. The Acute Onset of a Preexisting Condition(s) must occur after the effective date of the policy. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence. A Pre-existing Condition that is a chronic or congenital condition or that gradually becomes worse over time will not be considered Acute Onset. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs or Treatments existent or necessary prior to the Effective Date of coverage.
Additionally, per the above definition, the Acute Onset of Pre-existing Condition benefit excludes a preexisting condition that is a chronic or congenital condition or that gradually becomes worse over time. The Acute Onset of Pre-existing Condition benefit also requires that 'treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence'. Per the Claimant's Statement and Authorization form, symptoms started on 5/17/2014 and the medical records indicate that symptoms started 1 month prior to being seen by the doctor. In either case, this would not be within the 24 hour requirement of the onset of symptoms. Because of these reasons, Mr. [redacted] is not eligible for the Acute Onset of Pre-existing Condition benefit.
I hope this information will allow the Bureau to conclude the handling of this file. If I can be of any further assistance, please let me know.
Sincerely,
Jon [redacted]
Vice President, Claims and Compliance HCC Medical Insurance Services
This is in response to your recent inquiry on behalf of Ms....
[redacted]. Please be aware that this response may contain personal health information on the claimant. We trust the Department will only make this information available to those persons authorized to receive it. Ms. [redacted] purchased international travel coverage under our StudentSecure group travel insurance policy issued to the Atlas/International Citizens Group Insurance Trust, Hamilton Bermuda. Ms. [redacted] is a citizen and resident of China. The insurance is underwritten by Lloyds Syndicate 4141 and HCC Medical Insurance Services (HCC MIS) is the Coverholder and Administrator. After review of the information on file, it has been determined that we have sufficient information form Ms. [redacted] to complete processing the claims on file. The claims have been approved and an updated explanation of benefits will be sent to Ms. [redacted] directly within 10 business days.I hope this information will allow the Bureau to conclude the handling of this file. If I can be of any further assistance, please let me know. Sincerely, Lori L[redacted] Paralegal and Complaint Coordinator
Please find HCC Life Insurance Company's response attached. Thank you
I have reviewed Mr. [redacted]'s file. The application required underwriting and was approved on January 11, 2016. A cancellation request was received on January 13, 2016 and processed the same day. At that time, the premiums were refunded to Mr. [redacted].If I can be of further assistance, please let me...
know.Respectfully, Lori L[redacted]ParalegalHCC Life Insurance Company317/[email protected]
Please see the attached response to the following complaint: RE: Complainant: [redacted] ID number: [redacted] IN Revdex.com File #: [redacted]
I have provided Ms. [redacted] with my direct number to reach me in the future. HCC Life Insurance Company has received the authorization completed by Ms. [redacted] and forwarded it to the facility to release the requested medical records. Once medical records are returned, we will continue our review.If I can be of further assistance, please let me know. Respectfully, Lori LongParalegalHCC Life Insurance Company317/221-8013
please see the attached response to complaint: RE: Complainant: [redacted] IN Revdex.com File #: [redacted] Thank you, Lori L[redacted]
Please see the attached response to the following complaint: RE: IN Revdex.com File Number: [redacted] Complainant: [redacted]
Insured: [redacted]
We apologize for the delay in processing Mr. [redacted] claims. We are currently waiting for medical records from his provider's to determine our liability. Once these records are received, we can continue our processing.
I hope this information will allow the Bureau to conclude the handling of this...
file. If I can be of further assistance, please let me know.
Respectfully,
Brittani S[redacted] Compliance Assistant
770.693.6457
[redacted]@ hcclife.com
Please find attached HCC Life Insurance Company's response to your inquiry regarding Ms. [redacted]. Thank you
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that the response would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
Have all the records for my claims been requested so that they can be reviewed? If not, which records still need to be requested? Have any of my claims been reviewed yet? If so, what is the status?
Regards,
[redacted]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID 11492964, and have determined that the response would not resolve...
my complaint. For your reference, details of the offer I reviewed appear below.This company is attempting to say that every single claim I've had is a result of my hearing loss (which I've had since I was born), and therefore not covered. The issue that brought me into the doctor's office in the first place was headache and neck pain. Because I do have hearing loss (even though unrelated), my doctor put hearing loss as one of my diagnoses. It is UNRELATED to the headache/neck pain that brought me into the office. It is like saying someone's broken foot is a result of their hearing loss. Ridiculous. The first doctor I visited ordered an MRI and CT, an eye exam and blood work. He wanted to rule out any growths/tumors, etc. the MRI came back saying I have Chiari Malformation. Following these results, the doctor sent me to a neurologist and a neurosurgeon. The neurosurgeon ordered another MRI (a different type) and the neurologist did some additional blood work. They did these to best decide how to treat me and my headaches and the Chiari. HCC has chosen to deny all of these claims - the doctor visits, the blood work, every scan. They are still attempting to say 'condition not covered'. First of all, we didn't even know what condition it was at first - which was the reason for the tests. Second of all, it has nothing to do with my hearing loss. I have called multiple times and e-mailed and explained this. I filed my appeal in February and they had chosen to ignore it - until now after I filed an complaint. Now they are asking for records and saying they will review my appeal. I know I'm not the only person they are doing this to - I've read the other complaints. I have one guy who has contacted me a few times since filing the complaint and he acts like he actually wants to help. So I will send them my records, but I'm not holding my breath. The neurosurgeon wants to do surgery to alleviate the now daily neck/head pain I have. However, I can't even consider it until I am able to add to my husband's insurance and drop HCC. I've already racked up almost $20k in bills that are being denied. Lord knows how much this surgery would cost.
Regards,
Samantha Dyer
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that the response would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
Regards,
[redacted]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that the response would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
I find the response by HCC quite confusing. I am not sure what they mean when they say "HCC does not
hold any contracts with the provider. The contract is between the network and the provider". All I know is that I checked HCC website to see which facilities were considered in network, and I went to a facility that was listed as "In network" on their website. They also say "Mr. [redacted]’s policy
does not guarantee an innetwork provider. " If this is true they should provide documentation that my policy holds me responsible for an out of network provider even if I went to a facility that was within network and saw a provider of which I did not have a choice. They again have said " it has been determined that the claim on file has processed correctly." However, if this was the case from the very start, then why did they try negotiating for a discount? They must have known that something was amiss with this situation. As I stated in a previous response, the billing office for the emergency physician group said that charges for a visit are the same, but the patient financial responsibility depends on how the insurance processes it, whether it is considered in network or out of network. My argument from the start is that if I went to an facility considered in network by HCC and saw a provider who I had no choice, then I should be responsible for the in network charges regardless of how the provider shows up in HCC's system.Again, as I have said in the previous response, I am happy to file a complaint with [redacted] Hospital or the [redacted] group if HCC thinks the burden lies with them.
Regards,
[redacted]
Revdex.com:
I would like to find out when should I expect the reimbursement payment mail to my address? Could you ask them? Thank you.
Regards,
[redacted]
Please see the attached response to the following complaint: RE: Policy Administrator: Tokio Marine HCC Medical Insurance Services GroupRevdex.com ID number: [redacted]Complainant: Mr. [redacted]Insured: Mr. [redacted]November 3, 2016 Ms. [redacted] Revdex.com Serving Central Indiana 151 N Delaware Street #2020 Indianapolis, IN 46204-2599 RE: Policy Administrator: Tokio Marine HCC Medical Insurance Services Group Revdex.com ID number: [redacted] Complainant: Mr. [redacted] Insured: Mr. [redacted] Dear Ms. [redacted]: This is in response to your recent inquiry follow up on behalf of Mr. [redacted]. Please be aware that this response may contain personal health information on the claimant. We trust the Bureau will only make this information available to those persons authorized to receive it. While we understand that Mr. [redacted] is unhappy with the processing of the claim in question, HCC does not hold any contracts with the provider. The contract is between the network and the provider. Mr. [redacted]’s policy does not guarantee an innetwork provider. As stated in our previous response, HCC reached out to the provider in attempt to negotiate a discount and was unable to do so. We have again reviewed the file and it has been determined that the claim on file has processed correctly. If you need additional information, please let me know. Sincerely, Lori L[redacted] Paralegal and Complaints Coordinator Tokio Marine HCC Medical Insurance Services Group 317/221-8013 ll[redacted]@tmhcc.com
We have reviewed Mr. [redacted] file. It appears we are still waiting to receive medical records from Mr. [redacted] physician. Once we receive this information, we can continue our investigation. If...
you have any questions or concerns please let us know.Respectfully, [redacted]Compliance [email protected]
Regarding #1, the insured must complete the attached form and submitted. This must be completed and signed by the insured, MR. [redacted]. [redacted] cannot complete it on the insured behalf.Regarding #2, even though the claims were appropriately denied, HCCMIS will make an exception to allow the following claims as eligible in a good faith effort to resolve this issue. New EOBs will be mailed once the claims are reprocessed:[redacted] Sincerely, Jon P[redacted]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that the response would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
Hi,Thanks for taking steps to resolve issues related to insurance claim for Mr and Mrs [redacted]. However, there are few issues still need to resolved.Let me again divide my response in two parts.1) Mr [redacted])I’m satisfied with the resolution for all the claims provided by HCC Travel Insurance. However, Below is the request to adjust deductibles.Claim # [redacted] (198 USD) - Since this claim is already paid by me. Request you to pls adjust this amount in deductibles, If you want to issue cheque, Pls issue in the name of [redacted]. (Son of [redacted]).Claim # [redacted]- I agree that this claim is not covered under insurance policy and I’ll take care of the payment for this claim.I hope my request will be consider by HCC. 2) Mrs. [redacted])I’m attaching the claimant statement, submitted on 10/02/2015, where I clearly states that first onset of the condition is on 06/24/2015.Let me brief with situation.Mrs [redacted] felt mild pain in the night of 06/24/2015 during toilet and this pain was worsened in the morning of 06/25/2015. Hence, we immediately consulted Dr. [redacted] on 06/25/2015 itself. So, I believe this onset was well within the 24 hours.I hope above explanation and attached claimant statement will satisfy HCC and kindly urge you to process all the claims related to Mrs [redacted].Regards,
[redacted]
Regarding Mr.
[redacted]’s pharmacy claim ($198.00), this will be entered and processed. The claim number for this new claim is: [redacted].In regards to coinsurance for Mr. [redacted], the coinsurance was
waived. However, Mr. [redacted] is still
responsible for the $500 deductible. Below are how the claims will be processed with deductible:Claim # [redacted] - 59.40 towards the
deductible- no coinsurance taken Claim # [redacted] - $440.60 towards the deductible- no coinsurance
taken Claim # [redacted] - no deductible taken and no coinsurance taken.In regards to Ms. [redacted], these claims relate to a
procedure for a condition that occurred prior the issuance of the policy. The policy does have an acute onset of pre-existing
conditions benefit. However, treatment
must be obtained within 24 hours of the sudden and unexpected outbreak or
recurrence. Per the claim form, the
condition first began in the 3rd week of June. Since this Ms. [redacted] received treatment on 6/25/15, this would be
over the 24 hour requirement. Thus, the
claims were correctly denied as pre-existing.
Mr. [redacted] purchased international travel coverage under our Atlas America Program. The Group Master Policy is issued to the Atlas/International Citizens Group Insurance Trust, Hamilton Bermuda. This insurance is underwritten by Lloyds, London and HCC Medical Insurance Services (HCCMIS) is the...
Coverholder and Administrator.
Mr. [redacted], a citizen of India, purchased coverage with an effective date of 5/11/2014 and termination date of 5/28/2014 for his travel outside India including the United States.
HCCMIS has previously received and responded to a Pennsylvania Department of Insurance complaint from Mr. [redacted] regarding his claims denial. As explained in the Department of Insurance response, Mr. [redacted]'s was treated on 5/19/2014 and had surgery the same day. Per the medical records, the symptoms started one month prior. Based on this, Mr. [redacted]'s condition would be considered a preexisting condition under the policy. Please see the below definition and exclusions.
Exclusions:
42. Pre-existing Conditions — Charges resulting directly or indirectly from any Pre-existing Condition, as herein defined, are excluded from this insurance, except charges resulting directly from an Acute Onset of Pre-existing Condition, as herein defined, are covered for all Members subject to the limits set forth in the Schedule of Benefits and Limits.
Definitions:
Pre-existing Condition: Any (1) condition for which medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) was recommended or received during the 2 years immediately preceding the Certificate Effective Date; (2) condition that had manifested itself in such a manner that would have caused a reasonably prudent person to seek medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) within the 2 years immediately preceding the Certificate Effective Date; (3) injury, illness, sickness, disease, or other physical, medical, mental, or nervous conditions, disorder or ailment (whether known or unknown) that, with reasonable medical certainty, existed at the time of application or within the 2 years immediately preceding the Certificate Effective Date. For the purposes of the Complications of Pregnancy coverage offered hereunder, Pregnancy will not be included within the definition of a Preexisting Condition.
Acute Onset of Pre-existing Condition: The term "Acute Onset of a Pre-Existing Condition(s)" shall mean a sudden and unexpected outbreak or recurrence of a Pre-existing Condition(s) which occurs spontaneously and without advance warning either in the form of Physician recommendations or symptoms, is of short duration, is rapidly progressive, and requires urgent care. The Acute Onset of a Preexisting Condition(s) must occur after the effective date of the policy. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence. A Pre-existing Condition that is a chronic or congenital condition or that gradually becomes worse over time will not be considered Acute Onset. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs or Treatments existent or necessary prior to the Effective Date of coverage.
Additionally, per the above definition, the Acute Onset of Pre-existing Condition benefit excludes a preexisting condition that is a chronic or congenital condition or that gradually becomes worse over time. The Acute Onset of Pre-existing Condition benefit also requires that 'treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence'. Per the Claimant's Statement and Authorization form, symptoms started on 5/17/2014 and the medical records indicate that symptoms started 1 month prior to being seen by the doctor. In either case, this would not be within the 24 hour requirement of the onset of symptoms. Because of these reasons, Mr. [redacted] is not eligible for the Acute Onset of Pre-existing Condition benefit.
I hope this information will allow the Bureau to conclude the handling of this file. If I can be of any further assistance, please let me know.
Sincerely,
Jon [redacted]
Vice President, Claims and Compliance HCC Medical Insurance Services