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Court Says Routine Mammogram Is Not A Pre-Existing Condition

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Sometimes short-term health insurance companies claim that inconclusive diagnostic tests that occur before the date of the short term policy are pre-existing conditions. This illustrates how broadly these insurance companies will interpret the meaning of pre-existing condition. A recent Eleventh Circuit case (Jones v Golden Rule Insurance Company) illustrates this practice.

Jones v Golden Rule Insurance Company

Jones was leaving her job as a lawyer at a large Atlanta law firm to start her own firm. She planned to purchase a short-term health insurance policy to cover the gap between her old job and her new one.

While still covered by her employer’s policy, she had a routine mammogram but did not receive the results until a couple of months later. In the meantime, she purchased the short-term policy with Golden Rule Insurance Company.

When she received the mammogram results, the doctor recommend that she have further testing. Ultimately, she was diagnosed with breast cancer. Golden Rule denied her claims that the routine screening was a pre-existing condition under the insurance policy.

Golden Rule attempted to justify its decision by hiring an out-of-state doctor who had never seen or treated Jones to give an opinion that she had cancer before the effective date of the policy. The company also pointed to language which defined a pre-existing condition as “a condition for which medical advice, diagnosis, cure, or treatment was recommended or received within the 60 months immediately preceding the date” of the policy.

Using this language, the company argued that the routine mammogram was a “diagnosis” that had been recommended or received within the previous 60 months. The Eleventh Circuit rightly rejected this argument and, in a rare move, sent the case back down to the district court and ordered the district court to grant judgment in favor of the insured on the contract claim.

How You Can Fight Back Against The Insurance Companies

If an insurance company denies your claim or gives you a lowball offer, you may be facing the worst time in your life. You expected to have insurance as a safety net and now the insurance company has pulled that safety net away. Don’t accept that behavior as inevitable.

You can get help to make sure you get the insurance benefits you paid for. That is where the attorneys at Johnstone Carroll, LLC come in. If you are in an insurance dispute over policy coverage or the amount of compensation you are entitled to for a claim, contact our lawyers today. We are ready to help you recover the full amount of money or insurance coverage you are entitled to under your policy.

The articles on this blog are for informative purposes only and are no substitute for legal advice or an attorney-client relationship. If you are seeking legal advice, please contact our law firm directly.