Pre-existing condition - pregnancy

[spallanzani]

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

Hello everyone. I've enjoyed reading this forum for awhile and now I've run into a problem that has me very frightened. I hope you can help; thanks in advance.

I lost my full-time job on August 31, 2008. I signed up for health insurance through my grad school and my policy became active on January 21, 2009. Between those dates I was uninsured, so my gap in coverage is well over 63 days and pre-existing conditions would not be covered under my new policy.

I am now four months pregnant. My husband and I are happy about the baby but we were using contraception and definitely weren't planning children until I graduate.

At the time I lost my previous coverage, I was not pregnant, and while I was uninsured, I did not go to the doctor. I realized I might be pregnant in February 2009 and went to the doctor to have it confirmed on February 16th. At that time I was covered. However, my doctor estimates that conception would have taken place around December 30th, while I was uninsured.

My question is whether my pregnancy could be considered a pre-existing condition under my policy, and whether the conception date matters. I've talked to several people at my insurance company, and they all say they can't offer an opinion until they complete a 'pre-existing review.' I've sent in all the paperwork for this, and they've been reviewing for six weeks. Even when I specifically tell them I am not asking for a guarantee that any claims will be covered, all I want to know is based on my policy whether pregnancy coverage depends on the conception or the diagnosis date, they won't give me a solid answer.

Here's what my policy reads on pre-existing conditions:
' “Pre-existing Condition” is a Sickness, Injury, or related
condition for which a licensed Doctor was consulted; or
for which treatment or medication was prescribed within
twelve (12) months prior to the Effective Date of the Insured
Person’s coverage under this Policy.'

From reading that, it seems clear that if I didn't go to the doctor, the pregnancy couldn't be considered pre-existing, but all three insurance company phone reps told me pregnancy is different because it is an 'event' not a 'sickness, injury, or related condition.' Nothing in my policy mentions or defines and 'event.' Also, in the definitions section of the policy, 'sickness' specifically includes pregnancy:
'“Sickness” means sickness or disease which is the sole cause
of the Loss. Sickness includes both normal pregnancy and
Complications of Pregnancy. All sicknesses due to the same
or a related cause are considered one Sickness.'

If anybody has any information about whether or not my pregnancy is likely to be considered a pre-existing condition, please let me know. I'm trying to wait on the insurance company to complete their pre-existing review, but enrollment for classes next year ends soon and frankly, if my pregnancy is going to be 100% out of pocket, I'm going to have to drop out of school and I need to know that soon.

Thanks,

Kristen

[ecmst12]

Is this an individual policy? Most individual policies have a 2 year waiting period before maternity is covered at all.

[spallanzani]

Thanks for the response.

This is a group policy sponsored by a university. I have a link to the policy, if it would be helpful I will PM it to you but I would rather not post it on the thread.

I checked the rest of the policy and there isn't a waiting period listed for maternity coverage, at least not that I'm seeing anywhere.

Here's everything it lists under maternity care. Sorry I am so quote-happy:

Maternity Expense Benefit
We will pay benefits for an Insured Person’s Covered Charges
for maternity care, including Hospital, surgical and medical
care.
We cover charges for a minimum of 48 hours of inpatient care
following an uncomplicated vaginal delivery and a minimum
of 96 hours of inpatient care following an uncomplicated
cesarean section for a mother and her newborn child in a health
care facility, unless the attending Doctor in consultation with
the mother, makes a decision for an earlier discharge from the
Hospital. The Doctor’s approval to discharge must be made in
accordance with the most current version of the “Guidelines
for Perinatal Care” prepared by the American Academy of
Pediatrics and the American College of Obstetricians and
Gynecologists, or similar guidelines prepared by another
nationally recognized medical organization.
For a mother and newborn child who remain in the Hospital
for the minimum length of time stated above, We will pay
for one home health care visit if prescribed by the attending
Doctor.
For a mother and newborn child who have a shorter Hospital
stay, We will pay for post-discharge care to the mother and
her newborn. Post-discharge care will consist of two visits by
a Doctor or a registered professional nurse with experience in
maternal and child health nursing. The location and schedule
of the visits will be determined by the Doctor. One visit must
be in the Insured Person’s home. Services may be provided in
accordance with the most current version of the “Guidelines
for Perinatal Care” prepared by the American Academy of
Pediatrics and the American College of Obstetricians and
Gynecologists, or other nationally recognized medical
organization.
Newborn Infant Care – Newborn infant care is covered
when the infant is confined in the Hospital and has received
continuous Hospital care from the moment of birth. This
includes: (a) nursery charges; (b) charges for routine Doctor’s
examinations and tests; and (c) charges for routine procedures.
This benefit does not include circumcision. This benefit
also includes the necessary care and treatment of medically
diagnosed congenital defects and birth abnormalities of
newborn children covered from birth.
Covered services may be provided by a certified nursemidwife
under qualified medical direction if he or she is
affiliated with or practicing in conjunction with a licensed
facility.
(Mandated Benefits continued)
6
We cover such charges the same way We treat Covered
Charges for any other Sickness.

[cbg]

If this is an employer sponsored group policy, then under Federal law pregnancy CANNOT be considered a pre-existing condition no matter what.

[spallanzani]

It is not employer sponsored but it is a group policy; I am a grad student and the plan is sponsored by my university. Does that law apply to all group policies or only to those sponsored by employers? Do you happen to know which law or regulation that is, if you think it might apply?

Thank you.

[cbg]

HIPAA is the applicable law. Look at the third paragraph under Chapter 1.

If you still have questions after reviewing this, contact the US DOL.

[spallanzani]

After looking at HIPAA, I don't believe it covers my policy. It defines 'group health plan' specifically as being an employer-sponsored plan, which mine is not.

[ecmst12]

You may be ok either way. Your pregnancy was not diagnosed until after your effective date and if they treat it like every other sickness, then that is the date they should go by.