pre existing condition exclusions

[miktev]

What is the name of your state (only U.S. law)?
maryland

I've received a notice from my insurance company of my new job that they want all of my medical records to determine if they can deny payment of my current claims. I have had creditable coverage from 9/2007. My new policy became active in on 7/28/2008. According to my research into my current policy I have to wait 18 months for them to pay any claims related to what they determine to be a pre existing condition. With a ten month credit for creditable coverage that means I am not eligible for coverage until 2/2009. Is this right? and do I need to supply them with my medical records? and is there anything else I might be able to do?

[cbg]

Did you enroll in the coverage of your new plan as soon as you became eligible for it?

[TIMMAAYY]

Are they requiring you to have 18 months prior creditable coverage? How long before 9/2007 did you go without creditable coverage?

[miktev]

I switched jobs. My coverage at my old job (Anthem, ME) was in effect until 8/31/2008. My coverage at my new job (Guardian, MD) became effective on 7/28/2008. I haven't talked to Guardian yet but from my own research it appears that they are going to require 18 months prior coverage. Prior to 9/2007 I was uninsured from 8/2006.

[cbg]

You are reading it wrong, then. You're mixing up several different apples and oranges.

Under Federal law (HIPAA, to be precise) eighteen months is only permitted as a look-back period if you were a late enrollee, which you were not. Not only is there no gap in coverage, you were double covered for a month or so. Barring a late enrollment, the maximum an insurer can consider a condition is 12 months, minus any creditable coverage you had. You had between ten and eleven months creditable coverage, depending on when in September your coverage began. Any medical condition you may have received treatment for in the last six months, can only be considered pre-ex for the difference between twelve months and the ten or eleven months creditable coverage you had - in other words, a maximum of two months. A very far cry from eighteen.

With regards to providing them with your medical records, that's up to you, but doing so can make the difference between a condition being considered pre-ex and not. You aren't going to lose any coverage by doing so but you may lose some coverage by your refusal.

[TIMMAAYY]

I would provide them with whatever they ask for, since, as CBG said, they can only hold out on any pre-x conditions for the balance of 1 or 2 months out of the 12 months they can "look back".

After that you should be 100% covered, just like any other employee.

[miktev]

Thanks! that helps a lot.

[momm2500]

do you have the HIPAA certificates from your prior insurance plans? or they are called credibility of coverage letters. most insurance companies accept these which shows that you had previous non-stop insurance coverage. DO NOT send them your medical records.

[ecmst12]

Refusing to cooperate with the pre-x investigation is going to get your claims denied.