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What is Considered a Pre-Existing Condition?
If you had a diagnosis, treatment, or had symptoms which would have prompted a reasonable person to seek treatment or evaluation during the 12 months prior to membership, the condition will be considered pre-existing.
Exceptions: For back problems, blood diseases, cases of related cancers, diabetes, genetic disorders, heart conditions, hereditary diseases, or the replacement and maintenance of implanted prosthetics and orthotics, the condition will be considered pre-existing if you had a diagnosis, treatment, or had symptoms which would have prompted a reasonable person to seek treatment or evaluation during the 36 months prior to membership. Tests or a doctor’s statement may be required to verify the lapse of symptoms, treatment, and medication.
For the purposes of determining the eligibility of a bill for sharing, a reasonable person is someone who seeks medical attention (treatment or evaluation) when the symptoms he is experiencing:
- Prohibit him from performing typical life-tasks (i.e. changes your behavior on a regular basis),
- Exceed manageable pain levels (i.e. the symptoms require ongoing pain management), or
- Would prompt most people with similar symptoms to seek medical attention.
New bills are not considered as resulting from a pre-existing condition unless the new medical bills directly resulted from the prior condition. Be aware that even though a condition may appear at one time to have been cured, there could be a subsequent relapse or complication which is a result of the original condition. Samaritan Ministries may require that the member provide a written opinion from a physician that the current medical bill(s) was not due to the prior condition.
How do I determine if I have a pre-existing medical condition?
- Did I have a diagnosis, treatment, or symptoms which would have prompted a reasonable person to seek treatment or evaluation for this condition in the 12 months prior to my membership? If yes, condition is pre-existing. If no, proceed to the next question.
- Is my condition a back problem, blood disease, cancer, diabetes, genetic disorder, heart condition, hereditary disease, or related to an implanted prosthetic or orthotic? If yes, proceed to the next question. If no, condition is not pre-existing.
- Did I have a diagnosis, treatment, or symptoms which would have prompted a reasonable person to seek treatment or evaluation for this condition in the 36 months prior to my membership? If yes, condition is pre-existing. If no, condition is not pre-existing.
Samaritan Ministries’ Limitations for Pre-Existing Conditions
If a member with a pre-existing condition does not receive treatment for that condition for at least 24 consecutive months while an active member participating in Samaritan Given, the pre-existing condition will no longer be considered pre-existing and will be eligible for sharing.
“Treatment” refers here to services the member receives from a licensed medical provider for the purpose of managing or curing a medical condition. Follow up visits or evaluations are not considered “treatment” for the purpose of this guideline unless they reveal that the condition is not resolved.
This guideline applies also to members who previously participated in Samaritan Classic or Samaritan Basic but are now participating in Samaritan Given, as long as they were active members with no interruption over the 24 consecutive months.
Is my pre-existing condition still considered to be pre-existing, or is it now eligible for sharing?
Have you been a member of Samaritan Ministries for at least 24 consecutive months without receiving any treatment for this condition? If yes, condition is not considered pre-existing. If no, conditions is still considered pre-existing.
Exceptions for Diabetes and Cholesterol Level
Diabetes: Medical bills resulting from Type 1 diabetes that existed prior to a membership will not be eligible for sharing.
Diabetes Explained—By Type 1 diabetes (also called juvenile onset diabetes), we mean that condition where the body produces insufficient insulin. Type 2 diabetes (also called “non- insulin dependent diabetes”), the condition where your body is insulin resistant, and gestational diabetes, are subject to a 12-month symptom and treatment-free limitation. The condition commonly referred to as “pre-diabetes” will not be considered a pre-existing condition.
For Type 2 diabetes, you will have met the 12-month limitation if:
- at least 12 months have passed without any symptoms which would have prompted a reasonable person to seek diagnosis, care, treatment, or medication; and
- in the month before and the month after the 12-month period (and anytime you are tested in-between) your Hemoglobin A1C test level is 7% or below. Documentation of these test results must be provided to Samaritan Ministries.
Elevated Cholesterol: Elevated Cholesterol is not by itself considered a pre-existing condition, nor the mere fact that a person is taking a prescribed statin drug. However, if the drug is prescribed for or due to diagnosed arteriosclerosis for a particular location (e.g. heart, carotid artery), that condition would be pre-existing as to that location.
High Blood Pressure: Hight Blood Pressure will not be considered a pre-existing condition, regardless of symptoms, treatment, or medication prior to membership.
Source: Samaritan Ministries Member Guidelines
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