Hi,
I know this is a few months old but just wanted to say that i got denied for pre existing condition and did end up getting it approved.
But it took 8 months, a LOT of work, a lot of time, a lot of reading and a lot of carefully asking questions, trying to think of every possible angle. Asking questions to slowly back them into a corner without getting myself stuck in that corner. Taking their answers and probing, focusing on the holes. Having to “coach” my doctor on how the forms had to be filled out, having a specific framing to make everything fit.
I spent a lot of time trying to find anything that could be similar enough to my situation on canlii, i read the policy over and over and over again. In the end, I got them to a point where they hadn’t given me satisfactory answers about their interpretation and the denial but they couldn’t say anything more without sounding ridiculous. They simply stopped responding completely and stopped answering my questions.
Anyway, it would depend on the situation. I won because i had multiple diagnosis, one of them was pre existing, the other was not. I was able to clearly show that it was in remission & treatment was maintenance, so i challenged whether it was truly pre-existing.
Also, they were telling me that because symptoms of both conditions overlap, they were considering both pre-existing. Which is absurd because if they can’t prove the symptoms were related to the new diagnosis, obviously i have no way of proving they don’t. Even a doctor can’t,.
Also, the contract doesn’t say anything about pre-existing symptoms, it covers conditions - not symptoms. They said all kinds of things when i was asking questions and couldn’t walk them back later on but it made no sense, they were backed into a corner.
Anyway, I threw all of that (and more) at them. It was part of a complaint i sent to the ombudsman so it had lots of info - its like 30 pages, its insane, i was on a mission lol but i took so much put of me.
I got an approval, an apology and i was told the case managers would get coaching. I was told the legal department said i was correct about the multiple diagnosis. Even if one is pre-existing, if one is not, then it’s valid.
So basically, it depends on your situation. And if you have the energy to put into it. I was angry the whole time, that’s what was driving me.
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Edited to add: I just saw another thread where i discussed this HERE