Question regarding trauma injury not being covered due to pre-existing condition?

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Hi everyone

Not American (in Spain) so rules for sure would be different I guess I’m just wondering if anyone could have some possible insight to this issue.

My husband had eye surgery several years back. An implant and lens replacement. Successful surgery and no issues. We moved to Spain and of course pre-existing conditions are excluded. Which makes sense.

However a couple of months ago my husband had an accident and trauma to his eye. The lens came loose and he needs to have it reattached.

Insurance is saying it’s not covered due to the following:

We will contact you in response to your request for authorization for Ophthalmology/Replacement of INTRAOCULAR LENSES for xxx.

We have analyzed your specific case with our team of professionals, who have studied in detail the documentation you have provided us with. We are sorry to inform you that in the particular conditions of your policy you have the following exclusion clause

“Therapeutic acts, diagnostic tests, rehabilitation treatment, medical admissions and surgical treatments derived from pathologies of the left eye as well as their complications, consequences or sequels”.

Although, in this specific case, we cannot attend to your request, we are sensitive to your particular situation and if you require any clarification in this respect, we will attend to you in a more personalized manner through autorizaciones@dkvseguros.es, where you will be able to receive all the information you need.

The causation of the lens detaching is not due to anything with glaucoma.

Any ideas on how to get this remedied? We had the doctor submit saying it was due to a trauma to the eye.

There is a language barrier and we have to wonder if maybe we are not articulating the issue well enough. But I find it hard to believe that an accident will not cover an area of the body that has previously had issues? They aren’t directly related.

submitted by /u/lending_ear
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Hi everyone Not American (in Spain) so rules for sure would be different I guess I’m just wondering if anyone could have some possible insight to this issue. My husband had eye surgery several years back. An implant and lens replacement. Successful surgery and no issues. We moved to Spain and of course pre-existing conditions are excluded. Which makes sense. However a couple of months ago my husband had an accident and trauma to his eye. The lens came loose and he needs to have it reattached. Insurance is saying it’s not covered due to the following: We will contact you in response to your request for authorization for Ophthalmology/Replacement of INTRAOCULAR LENSES for xxx. We have analyzed your specific case with our team of professionals, who have studied in detail the documentation you have provided us with. We are sorry to inform you that in the particular conditions of your policy you have the following exclusion clause “Therapeutic acts, diagnostic tests, rehabilitation treatment, medical admissions and surgical treatments derived from pathologies of the left eye as well as their complications, consequences or sequels”. Although, in this specific case, we cannot attend to your request, we are sensitive to your particular situation and if you require any clarification in this respect, we will attend to you in a more personalized manner through autorizaciones@dkvseguros.es, where you will be able to receive all the information you need. The causation of the lens detaching is not due to anything with glaucoma. Any ideas on how to get this remedied? We had the doctor submit saying it was due to a trauma to the eye. There is a language barrier and we have to wonder if maybe we are not articulating the issue well enough. But I find it hard to believe that an accident will not cover an area of the body that has previously had issues? They aren’t directly related.
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