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Pre-Existing Condition

I changed jobs in May, and my health insurance from my previous job expired on 4/21/13, and my new insurance went into effect 7/1/13. At the end of September, I was forced by my doctor to make an appointment and go see him during a migraine before he would authorize a refill for my sumatriptan. I say "forced" because #1-I see him regularly, about every 3 months for ongoing follow-up for my migraines and fibromyalgia, #2-I had just seen him at the end of July after my new insurance went into effect, and #3-I have always used sumatriptan as treatment and only got 9 per month-not like I was asking for an excessive amount for a refill of 9 after two months. So, I felt it was unnecessary for me to leave work and drive over there to the doctor's office in the middle of a horrendous migraine episode just to get him to send in a refill of the medicine we both already knew would abort the episode, so I could waste more time away from work to go out by my house to pick it up, so I could function well enough to then go back to work. I could have just taken my lunch hour, gone straight to the pharmacy, and been back well within my allotted 30 minutes if he had just approved the refill. Instead I was gone from work for over 3 hours, and they told me not to bother coming back that day. They were not happy, nor were they sympathetic.

Anyway, the point of this is, when they submitted the visit to my insurance, I assume they put down "migraine" as the reason for my visit, and now the insurance company is refusing to pay the bill - and refusing to pay for my migraine meds any more - because they "suspect it is a pre-existing condition." I am 46 and have been suffering from migraines for over 32 years - heck yes, it's a pre-existing condition. It seems stupid to me for them to apply that term to migraines, and even more so for them to use it as a reason to get out of paying claims. Does this mean they will only pay for migraine treatment if I only started having them after July 1, 2013? They sent me a questionnaire to fill out, where I had to answer whether I had been treated for "this condition" prior to July 1, 2013, (when my insurance went into effect.) I said NO - my rationale being, "No, I was not treated for THIS migraine before July 1, only on Sept. 27th." If they want to deal in semantics, I can do semantics. We'll see if they buy it or not. I'm betting not, and then I will be stuck paying $300 for my minimum supply of sumatriptan every month...and the neurologist my PCP wants to send me to? Forget that! This may be the end of any treatment for my migraines beyond OTC stuff that very rarely works.

Has anyone else been through this with insurance before - determining that your migraines are a pre-existing condition so they don't have to pay?

  1. gaile.smith

    I suggest you get with your doctor's office to find out exactly how your visit was billed. Often a single word or even two can be the difference between payment and denial.

    Unfortunately, I do know some patients have been told Migraine is a pre-existing condition and have been on their own to pay for treatment, etc. Most of the time doctors are very good about helping these patients. You often have to ask them, but they often offer discounts and free samples for patients who are in this position.

    Please be careful with your insurance company. It is very easy for them to contact your doctor and ask him/her if you had this diagnosis prior to the date of your visit. Your doctor will answer them and your negative answer could get you dropped from your insurance. This would be really bad. I'm going to send Diana Lee a quickie email and see if she can drop in and help you with other ideas, as she is our legal brain and very good at helping patients with problems like this. She's a great person to have on your side!


    1. Thank you, Ellen. I will take any and all advice. I should note that I am aware that the insurance company can find out anything - they included a general release of information that I had to also sign and send back with the quiz form. 😀 It just happened that during the time period they specified in their questionnaire, I had NOT seen my doctor for nor been treated for migraines by him. At the beginning of that time period (they specified early February to early June), I was not having migraines frequently at all (February) and by June, I had been without insurance for almost two months and could not afford to go to the doctor at all. So, it was a truthful answer, and they will find no records of treatment at my doctor's office, nor at the pharmacy I use, should they check there.

      I will definitely look forward to hearing what Diana has to say. Thank you so much for getting her involved! I really appreciate your help and insight.


      1. Gail,

        You're welcome. I really do hope this works out okay for you!!


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