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  • Definition/exclusions of acute onset of pre-existing condition

    Hello,

    My parents (dad:59 and mom: 55) will be visiting next month on B2 visa. Mom is generally healthy, but dad has low vision due to diabetic retinopathy, which puts him at risk of certain things such as eye complications, diabetic foot, falls, or something more serius. We are taking due care to ensure proper maintenance of his health (medicines from India, monitoring pressure and diabetes at home).

    From our point of view, we do not want any emergency to occur. So, I am checking with diabetologists and retina specialists in the area what it would cost to consult them on regular schedule (1 or 2 months) without coverage from insurance. Happy to pay for comprehensive insurance + regular maintenance.

    Let's say we find out during regular checkup that dad needs to undergo urgent medical treatment (laser ablation to fix rapidly rising glaucoma, retinal surgery to correct detachment) the very next day. How about injury due to fall that occurs due to low vision? Will these be considered an acute onset by insurance companies such as Atlas America and Patriot? Do these plans cover urgent outpatient treatments?

    Also, what will be more cost-effective: to combine high-risk and low-risk persons on single policy, or to buy separate policies for them.

    While I appreciate information from Insubuy, if people other than Insubuy are reading this forum, please chip in. Such questions are important to the community and I pledge to report my honest experience.

    Thanks
    Eastbound

  • #2
    It is not possible to tell you in advance with certainty whether a particular combination of incidents would be covered or not as it is determined after the fact by the claims department based on the attending physician report and all medical records. There is no specific exclusion for urgent outpatient treatment, as long as it is new medical condition or acute onset of pre-existing condition.

    However, in my opinion, most of the things you describe would most likely be excluded.

    For some information regarding acute onset of pre-existing conditions, please read https://www.insubuy.com/visitor-insu...ng-conditions/ That would give you useful information.

    Whether you buy separate policy or combined policy, the total price would be the same as everything is per person. However, we always recommend everyone to buy separate policies for each person.

    If you have any other questions, please feel free to post them here or contact us at any time.
    Thanks & Regards
    Insubuy
    Toll Free: (866) INSUBUY
    Local: (972) 985-4400
    Fax: (972) 767-4470
    Website: http://www.insubuy.com

    Comment


    • #3
      Hi Eastbound,
      Hope your parents have a safe trip, do update your post with any info on which insurance you bought and if you had to use it, how was the experience.
      Thanks.
      H

      Comment


      • #4
        Huafen,
        My parents have not yet arrived. I am still evaluating insurance options, but Atlas America looks like the most functional choice.

        Insubuy,
        Reading the atlas america's conditions, I notice the difference between urgent care and emergency care, mainly the penalty for visiting emergency room if the patient is not 'admitted'.

        Are true vision threatening (but, not life threatening) emergencies classified under emergencies or urgent care or neither?
        Is a visit to emergency room penalized if the patient is treated on 'outpatient' basis for vision threatening emergency?

        Eastbound.

        Comment


        • #5
          It is not possible for us to give general advice whether the person should visit urgent care or emergency room in a given situation. Please use your best judgement. Please read https://www.insubuy.com/what-is-visitors-insurance/ for more information.

          Under Atlas America, for any sickness, if you visit an emergency room and if you are not subsequently admitted into the hospital (that is, inpatient. Not outpatient), you will have to pay $200 for each use of the emergency room.

          Even under our Blue Cross Blue Shield of Texas (group insurance for our company), the emergency room visit copay is $500, no matter what. All Obamacare compliant plans have ER copay of $300, $400, $500 or $600 copay, depending upon whether it is Platinum, Gold, Silver or Bronze level plan. And this is in spite we pay thousands of dollars in premium every month.

          Therefore, I consider that such a provision in Atlas America is very reasonable. Persons can purchase it online at https://www.insubuy.com/atlasamerica-insurance/

          Please let us know if you have any other questions.
          Thanks & Regards
          Insubuy
          Toll Free: (866) INSUBUY
          Local: (972) 985-4400
          Fax: (972) 767-4470
          Website: http://www.insubuy.com

          Comment


          • #6
            Insubuy,
            My questions were specific (vision-threatening situation). The barometer of reasonableness will vary from state to state, person to person, country to country. My employer-sponsored health insurance (MA) has emergency room co-pay of $50 (not 500) 'no matter what' and doesn't cost thousands of dollars in premium every month (my+employer combined).

            If someone is about to lose vision and vision-saving treatment is provided on outpatient basis, it is a genuine emergency treatment - as far as doctors and hospitals define it.

            But, it is useful to learn the interpretation by insurance companies.

            Originally posted by insubuy View Post
            It is not possible for us to give general advice whether the person should visit urgent care or emergency room in a given situation. Please use your best judgement. Please read https://www.insubuy.com/what-is-visitors-insurance/ for more information.

            Under Atlas America, for any sickness, if you visit an emergency room and if you are not subsequently admitted into the hospital (that is, inpatient. Not outpatient), you will have to pay $200 for each use of the emergency room.

            Even under our Blue Cross Blue Shield of Texas (group insurance for our company), the emergency room visit copay is $500, no matter what. All Obamacare compliant plans have ER copay of $300, $400, $500 or $600 copay, depending upon whether it is Platinum, Gold, Silver or Bronze level plan. And this is in spite we pay thousands of dollars in premium every month.

            Therefore, I consider that such a provision in Atlas America is very reasonable. Persons can purchase it online at https://www.insubuy.com/atlasamerica-insurance/

            Please let us know if you have any other questions.

            Comment


            • #7
              If your ER copay is $50 now, you must be working for a large employer. In that case, $500 type ER copay is coming to you in 2015, as Obamacare compliance has been delayed by a year for large group health insurance. By the way, I am paying close to $2,000/month (employer + employee contributions combined) for my family and we have silver plan. Before Obamacare compliance, our ER copay was $100.

              In any case, in Atlas America, if you are not admitted into the hospital, you are subject to $200 additional payment per visit. If you have already not done so, please read the last paragraph under 'Abuse of Emergency Room' section at https://www.insubuy.com/what-is-visitors-insurance/ for further information.
              Thanks & Regards
              Insubuy
              Toll Free: (866) INSUBUY
              Local: (972) 985-4400
              Fax: (972) 767-4470
              Website: http://www.insubuy.com

              Comment


              • #8
                I work for employer with ~200 FTEs - don't know if that counts as large or small. I+employer pay the same amount as you/month.

                After obamacare took effect in 2014, our insurance cost dropped by $25 per month because of the provision that insurance companies cannot make more than certain % profit. I haven't seen any suggestion/news/data that tells me that our copay will go up in 2015. This seems to be a case where law is one thing and how different states chose to implement is another! All of us are subject to wrong priorities of the system - insurance companies bottom line is prioritized over quality of life and care.

                I understand that people 'abuse of emergency room'. That is not the point I am making.

                The point is that insurance companies ignore medical science to maximize their profit - such as, emergency eye care is categorically different from something like pain due to kidney stone. It just happens that medical advances allow treatment of eye on ambulatory/outpatient basis and that is simply not possible with many other emergency situations.

                Of course, you are a broker and an honest one from what I read. Let's leave it at that.

                Originally posted by insubuy View Post
                If your ER copay is $50 now, you must be working for a large employer. In that case, $500 type ER copay is coming to you in 2015, as Obamacare compliance has been delayed by a year for large group health insurance. By the way, I am paying close to $2,000/month (employer + employee contributions combined) for my family and we have silver plan. Before Obamacare compliance, our ER copay was $100.

                In any case, in Atlas America, if you are not admitted into the hospital, you are subject to $200 additional payment per visit. If you have already not done so, please read the last paragraph under 'Abuse of Emergency Room' section at https://www.insubuy.com/what-is-visitors-insurance/ for further information.

                Comment


                • #9
                  Your is considered large employer.

                  In my honest opinion, rather than worrying about additional $200, you need to really worry about whether this situation would be covered at all in the first place or it would be excluded as ineligible expense.
                  Thanks & Regards
                  Insubuy
                  Toll Free: (866) INSUBUY
                  Local: (972) 985-4400
                  Fax: (972) 767-4470
                  Website: http://www.insubuy.com

                  Comment


                  • #10
                    Yes Insubuy, getting back to the main point.

                    1) List of exclusions in comprehensive policies say "Eye surgery, such as corrective refractive surgery, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.'
                    I read this as excluding surgeries such as LASIK, but not surgeries such as cataract (of course assuming other clauses such as pre-ex do not exclude it). Am I correct?
                    Some fixed coverage policies do not have such wording.

                    If interested in insuring emergency (I mean serious) eye care , should I opt for fixed or comprehensive?

                    2) In the event of dispute about the interpretation of the certificate wordings, what recourse does the insured have?


                    Originally posted by insubuy View Post
                    Your is considered large employer.

                    In my honest opinion, rather than worrying about additional $200, you need to really worry about whether this situation would be covered at all in the first place or it would be excluded as ineligible expense.

                    Comment


                    • #11
                      Insubuy, please answer my following question

                      If a female is about 57, and she is healthy with no eye problem. She came to the US to visit her daught. Her daughter buys a Patriot Health Insurance for her with a period of 6 months. During the mom's visit, she experienced blur vision which she never has before. Her daughter takes her to the hospital, and the doctor says that the mom has cataract and she needs surgery. Please tell me will the health insurance the daughter buys cover for this surgery?

                      Thanks

                      Comment


                      • #12
                        Insubuy, please answer my following question

                        If a female is about 57, and she is healthy with no eye problem. She came to the US to visit her daught. Her daughter buys a Patriot Health Insurance for her with a period of 6 months. During the mom's visit, she experienced blur vision which she never has before. Her daughter takes her to the hospital, and the doctor says that the mom has cataract and she needs surgery. Please tell me will the health insurance the daughter buys cover for this surgery?

                        Thanks

                        Comment


                        • #13
                          Have you already purchased the insurance or are you planning to purchase?

                          If you have already purchased, please call our office and provide with your certificate number so that we can provide you a specific answer.

                          If you are planning to purchase, how are you coming up with such specific example? What exactly is going on?
                          Thanks & Regards
                          Insubuy
                          Toll Free: (866) INSUBUY
                          Local: (972) 985-4400
                          Fax: (972) 767-4470
                          Website: http://www.insubuy.com

                          Comment


                          • #14
                            Originally posted by insubuy View Post
                            Have you already purchased the insurance or are you planning to purchase?

                            If you have already purchased, please call our office and provide with your certificate number so that we can provide you a specific answer.

                            If you are planning to purchase, how are you coming up with such specific example? What exactly is going on?
                            What do you expect? I am a writer, after going through a lot of topics and threads about your insurance plans, and looking at the way you answer members, I can come up with several scenario.

                            By the way, I am 24, and during my last visit to physician, I found out that I have to have cataract surgery. And I do not know if this belongs to pre-existing conditions. Ugh!

                            Comment


                            • #15
                              That would be considered pre-existing condition and not covered.
                              Thanks & Regards
                              Insubuy
                              Toll Free: (866) INSUBUY
                              Local: (972) 985-4400
                              Fax: (972) 767-4470
                              Website: http://www.insubuy.com

                              Comment

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