Pre-existing Condition Clause

[Toogoofy317]

When I left Disney to work at the hospital. I had no lapse in insurance coverage. Actually, I had both for two months just to make sure I was covered under the Cobra Act. Well come to find out the insurance company does not want to cover any of my medical bills for the past year. As you know thats a lot of visits and money. I sent them my certificate of portability about six months ago and again last week. Today I got a letter stating that all of my claims are denied due to my pre-existing condition.

Is this legal? If it is I am financially ruined. What would be my next step?

Mary S.

[Burton Borrok]

Well Pumpkin,
I would suggest you first drag out the insurance policy that is now in force and read it slowly and carefully. Find out there definition of pre-existing conditions, and whether the transfer from the Cobra policy has any bearing.

Next, check the law in regard to pre-existing conditions under both State and Federal guidelines, and the transferability from your old policy to the new one (I assume there are two insurance companies involved between Disney and the Hospital.)

If, after reading the policy and checking the law covering such cases, you think you are right - go get an ACLU lawyer, or a Legal Aid lawyer, or the local Bar Association, or any legal society that may be available to you locally, and get their help in processing your claims. If on the other hand, it appears that the insurance company has the right to disallow your claims, see if the hospitals involved will waive any fees due. If not, all you can do is file for bankruptcy. The whole reason for the bankruptcy laws is to allow people with no other options to continue living a life outside of slavery.

By the way, if appropriate, find out how long an insurance company can disallow claims based on pre-existing conditions. If memory serves, that may only be for six months before they must accept charges (or a year for senior citizens.) In any case you can IM or email me if you need me and I will try to help you as much as I can.
Grandpa

[Lisa Salberg]

You have to look at State law and Federal Law and read the policy to know for sure what your rights are - I can not give you a blanket 'Yes or No' with out looking at all of the information.

Lisa

[mtlieb]

Mary,

I wanted to wait until the 'HCMA' answered first since technically only staff and moderators are supposed to answer here. I've lived in many states and also dealt with Cobra in the past and i have been surprised how much the laws vary. I looked into Cobra in Montana when a project ended and assumed that if i paid the full premium out of my pocket the covereage would be the same as the insurance it was 'replacing'. Isn't that what Cobra is for, so you can continue your present coverage temporarily until you can get a new one? Boy was i wrong. It covered almost nothing.

Jim

[Linda]

Now I must check this out also. We have one more wk to deal with this before the BD kicks our son off our policy. Linda

[Burton Borrok]

Hey Linda,
If it turns out that your policy has such a clause, sometimes your son can avoid the problem by taking out a policy (without a break) with the same company.

If the problem exists, talk to a representative of the insurance company about it. They will often have a method of continuing your son in his own policy as an extension of his previous coverage under your family plan. That should avoid any ‘prior condition’ problems, which you might encounter if he switches to another carrier.

I am often amazed by how many people do not read their insurance policies until they get into trouble and it is then too late to do anything about it. I am convinced the insurance companies try to make the policies as difficult to understand as they can still get away with. In the old days, before the government stepped in to regulate it, many lawyers had problems understanding the policies and had to take special training to cope with them. Things are nowhere near as bad today, but you still have to read it and understand what is and is not covered – and to what extent.

Many years ago I used to write international contracts for a major company, and we won the services of more then one distributor just because they could understand our contracts much easier then our competitor’s. Companies who deal in contractual arrangements either learn to understand what they commit to, or they are not around very long. People should take care of themselves just as scrupulously.
Burt

[Sarah]

worst case scenario

Dear Mary,

I'm so sorry. I hope you have some leverage and can get them to turn around on this. It sounds like you need to find a friendly lawyer who can write the company a letter. Insurance companies respond better to lawyers.

I, too, was under the impression that if you have had continuous coverage for the prior 12 months, you can't be denied under a pre-existing condition clause.

Here are some links I found: http://www.cmcinsurance.com/hipaa.htm

http://www.hipaanet.com/cbrr.htm

most importantly:
http://www.lnjins.com/portability.htm

read the LAST post on this page:
http://forum.freeadvice.com/archive/.../t-173302.html

[Linda]

Thanks Burt, we are using the same company. I guess I misunderstood Mary's post and thought she used the same company and had the problem. I'm still going to read fine print, but we should be good. Linda

[Lisa Salberg]

There are many questions that need to be answered prior to passing judgement on what is going on with this matter.

I am not currently aware of any specific problems with Florida law on insurance, nor do I think we will find one as many others in FL have moved policies with no problems at all.

It is important to check the POLICIES that were purchased and read the details.

Lisa

[Toogoofy317]

This is what my policy says:

" Unless you can provide proof of continuous coverage for the 12 month period immediatly preceeding your effective date of ceoverage, without a break in coverage of 63 days of more, the plan will not cover pre-existing conditions. This will include expenses incurred as the result of any injury, illness or related conditions for which you or your covered dependent have consulted with a physicican or received any medication, medical care or treatment within the three-month period immediatly prior to the effective date of coverage ( or six-month period for the select plan). Benefits wil not be paid on that particular condition until the individual has been covered under the plan for one year. In order to have any portion of the pre-ex period waived, you sould contact you previous health plan provider to obtain a certificate of creditable coverage and submit it to the benefits office."

I went to the HR person at work. And they said that what the company was doing was wrong. They gave me the number for a supervisor's number. They also gave me a number for a financial specialst too see if I can get some charity help.

mary S.

[Burton Borrok]

Hi Mary,
If I may suggest – go ahead with everything you have been advised to do – but also contact your previous insurance company and request an expedited copy of a Certificate of Creditable Coverage, which should include the total period of time you carried the policy - including the period under the Cobra Act. (Pick it up yourself if you have the time.)

“you should contact your previous health plan provider to obtain a certificate of creditable coverage and submit it to the benefits office."

Make a copy of the certificate for your own records and send or carry the original to the new insurance company’s benefits office – mailed Certified – Return Receipt, or signed for – If you hand deliver it.

By the wording in their own policy, they will then have to provide the insurance coverage to you – or be in breach of contract. In my opinion they are trying to avoid making the payments because they have not received the certificate yet, but once it is supplied to them they will pay.
Burt

[Lisa Salberg]

Mary,
Have you sent your new insurance company your "portability certificate" if not - do so ASAP - if you have send a 2nd copy as the original may have been lost.

Once you are sure they have the portability certificate in hand and they review the claims - then we will know if they are following the law or not.

Lisa

[Laoshur]

Mary,

I don't know anything about the Florida laws, but your experience sounds very familiar. When my daughter was in college, every single time she made a claim, the insurance company rejected it. Each time, when we called, they said that they had to have proof that she was enrolled. On one case this was literally one day after we had submitted proof.

In her last semester of college I took a one semester leave of absence and used my husband's insurance as my sole carrier. Once again they denied every claim on the basis that either this was preexisting (I had been on their insurance as a secondary for many years so preexisting did not count) or they claimed that they thought I had a primary carrier, even though I had repeatedly submitted proof that they were my sole carrier. Finally, at the advice of a friend who worked in insurance claims for a doctor's office, I called them and said that if any more claims were rejected, I would call the state insurance commission and give them documented evidence that they were rejecting claims illegally. Of course they argued that they would never illegally reject claims, so I just calmly said that I had been keeping track of each rejection and the fact that each time I called, they retracted the rejection and that I would gladly submit the data to the state insurance commission. Well, all I can say is that to this day I have never had another claim rejected!

Try it, you may like it!

Rhoda

[Toogoofy317]

Yes! Of course I sent the insurance certificate of portability Three to four times in fact! I think I stated that in my initial post? (sorry got a 100.2 fever and fighting to not have another visit),

They cofirmed that I sent it to them.

Mary S.

[Burton Borrok]

Listen my hot one,
If they have confirmed (in writing) that they are in receipt of the portability certificate – or you have other proof that it was supplied to them - - and they still deny your claim on the pre-existing condition clause – they are in demonstratable breach of contract. (If any part of this is missing, you can send them another copy certified return receipt (for proof), and include a letter asking for a review of the claim in the certified transmittal. (Keep dated copies for your own records.)

The next step I suggest is to go after them with an attorney (Legal aide – etc) and also contact the state board of insurance. If your legal help doesn’t know (care) what to do about it, and the state authority does not respond, please contact me and I will suggest a possible course you might want to follow.

Get well, and stay that way. (Do you think the fever is a result of your non-HCM problems?)
Burt