Pre-Existing Clause?

[Catspan]

Have you been advised by a physician to have surgery, medical tests, treatment or therapy that has not been performed?
That's the question I am concerned with. He felt he answered that question honestly because his physician said he felt he did need heart surgery and then he went to a cardiologist and he said he did not feel that surgery was necessary. He felt though he wanted a 2nd opinion and did that today, and will have the results and consultation on Jan. 4th (on his new med sup plan) So, in answering that question he was not advised because he was already given the answer by the cardiologist but wanted to seek a 2nd opinion.

 

[DS4]

Answering the "yes/no" questions correctly on the application, and, whether the pre x applies are two separate issues.

 

[Catspan]

Do you feel he answered that question incorrectly? He was going with what the last doctor he saw, his cardiologist which said he did not need surgery or any further testing.

 

[G.Gordon]

Slippery slope. If it were me I'd tell him we're resetting his effective date to 2/1/10 (still inside the OEP) and outside the "getting results" of medical test question.

 

[sman]

I refer you back to my last post.

CALL AN UNDERWRITER!!!

You are wasting precious time trying to get your answer here. None of us can approve this case. Only the underwriter can.

Do you feel he answered that question incorrectly? He was going with what the last doctor he saw, his cardiologist which said he did not need surgery or any further testing.

 

[Russ]

Have you been advised by a physician to have surgery, medical tests, treatment or therapy that has not been performed?
That's the question I am concerned with. He felt he answered that question honestly because his physician said he felt he did need heart surgery and then he went to a cardiologist and he said he did not feel that surgery was necessary. He felt though he wanted a 2nd opinion and did that today, and will have the results and consultation on Jan. 4th (on his new med sup plan) So, in answering that question he was not advised because he was already given the answer by the cardiologist but wanted to seek a 2nd opinion.

Based on what you stated, his physician DID advise him he felt he needed heart surgery. His cardiologist felt he didn't.

I don't blame him for getting a 2nd opinion, which he did today. I hope he went to another cardiologist. What if those results indicate to that doctor that he did need surgery?

 

[DS4]

As I'm not licensed in Ohio, I don't know your states various guarantee issue scenarios regarding someone going from a MA to a Med supp.
Here are a few Federal guarantees,
1)MA discontinued providing coverage in your area.
2)Is insured dis-enrolling within 12 months of initial enrollment in Part B?
"Yes" to either of these and you are home free! Provided you supplied UoO with evidence of such event.

 

[Catspan]

I just wanted to thank you all so much for your replies. After what many of you suggested and the last reply from sman, I called a senior underwriter. I documented her name too just in case.
She said that all questions answered are according to the date the application was signed and at that time, he had not decided to go for a 2nd opinion as well as when a policy is issued no pre-existing conditions applies.
I feel so much better now and am glad that I posted this on here today because that is what made me call an underwriter.
Thanks for helping out a new agent. This board is very helpful to me.

 

[sman]

Cat,

That doesn't make sense to me. Prior to the 2nd opinion you stated the client was advised to have surgery. That would mean he would answer 'yes' to the aforementioned question which would mean a decline.

I'm not trying to be a pain here. You seem to really want to do what is right by the client so I would make sure before moving forward.

 

[Catspan]

I explained that to the underwriter, that he was advised to have surgery by his physician but was referred to a specialist who said he did not need the surgery. She reassured me that it should not be an issue and that pre-existing conditions won't apply to him. I got her name and documented the call. She understood how concerned I was for this gentleman and making sure there would not be any issues and she was a senior underwriter so I don't think I have reason to worry anymore