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Secondary insurance claim due to pre-existing condition

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

I had an inpatient surgery in March 2014. I had primary insurance (through my employer) and a secondary policy through my university, which was a full major health insurance plan (AIG trough First Health Network). Primary paid, no issue there. The secondary has not paid. Initially, they denied stating I needed to file with worker's compensation insurance. The claim was worker's comp several years ago, but was closed. I sought further treatment more recently under my own insurance. Once I showed them that documentation, they changed their denial to a different reason.

The coverage began effective January 1, 2014. As previously stated, surgery was March 2014. Their current denial reason is that the policy has a pre-existing condition clause that does not cover conditions that were treated within 6 months of the policy effective date. It is my understanding that beginning 2014 the Affordable Healthcare Act banned denails for pre-existing conditions. So is what they are doing legal? Is there some part of the Act that allows this? Thanks.
 


FlyingRon

Senior Member
Actually, you may have hit the one case where the ACA doesn't ban pre-existing condition denials most likely. "Grandfathered insdividual plans" are ones in existence from before March 2010 and haven't substantially changed. If this is such a plan, they don't have to cover this. You can find out for sure by asking for the summary of benefits.
 
Actually, you may have hit the one case where the ACA doesn't ban pre-existing condition denials most likely. "Grandfathered insdividual plans" are ones in existence from before March 2010 and haven't substantially changed. If this is such a plan, they don't have to cover this. You can find out for sure by asking for the summary of benefits.
The only thing I see is "The Policy becomes effective at 12:01 a.m. on August 19, 2013 and terminates at 11:59 p.m. on June 18, 2014. The coverage of an eligible student who enrolls for coverage under this Plan during an open enrollment period shall take effect at 12:01 a.m. on the latest of the following dates: (1) the Policy Effective Date; (2) the day after the date for which the first premium for the Covered Student’s coverage is received by the Company; (3) the date the University’s/College’s term of coverage begins; or (4) the date the student becomes a member of an eligible class of persons as described in the Description of Class section of the Schedule of Benefits in the Policy on file with the University/College."

For clarification, my coverage began on Januyar 1, 2014 because that is when I enrolled in school. Thanks.
 

cbg

I'm a Northern Girl
If this is one of the exceptions Ron mentioned, it's not a matter of when you joined the plan; it's a matter of when the plan itself was created. There's not going to be a plan where there is a pre-ex clause for some people and not others depending on when they joined the plan - either the plan contains a pre-ex clause or it doesn't.
 

cbg

I'm a Northern Girl
Some group policies are also exempted.

https://www.healthcare.gov/health-care-law-protections/grandfathered-plans/
 
is there something I'm missing? This seems pretty definitive. It specifically addresses student health insurance.

http://www.acha.org/topics/affordable_care_act/faqs_for_individualcoverageclassification.cfm

"Q1: When are the final regulations effective?
A1. The final regulations generally became effective for policy years beginning on or after July 1, 2012. The medical loss ratio amendments became effective for all student health insurance plans as of January 1, 2013 regardless of the policy year. Grandfathering rules are effective for individual health insurance policies in effect on March 23, 2010; however, policy changes such as increases in coinsurance, elimination of benefits or significant increases in co-payments or cost-sharing will cause a loss of grandfathered status. Any coverage in which a student was newly enrolled after March 23, 2010, is non-grandfathered and subject to the ACA requirements applicable to student health insurance plans under the final regulations."
 

lkc15507

Member
"Plan Year"

The ACA rules go into effect for "Plan Years" beginning on or after January 1, 2014. A plan year may or may not be a calendar year. I am still reviewing Pre-X for our plans with November and December renewal dates.
 

lkc15507

Member
CFR 147.108

You can generally Google preexisting and ACA and come up with the information on various websites such as HHS.gov and Healthcare.gov
 
CFR 147.108

You can generally Google preexisting and ACA and come up with the information on various websites such as HHS.gov and Healthcare.gov
So how does this not contradict what I quoted earlier from the ACA website?: "Any coverage in which a student was newly enrolled after March 23, 2010, is non-grandfathered and subject to the ACA requirements applicable to student health insurance plans under the final regulations."

Thanks.
 
So, the insurance company has taken over 30 days to respond to my appeal. It is my understanding that this is a violation of the law. If that's correct, do I have a case to submit to an independent review board and win the appeal on that technicatliy that they have taken longer than 30 days to respond?
 

lkc15507

Member
So how does this not contradict what I quoted earlier from the ACA website?: "Any coverage in which a student was newly enrolled after March 23, 2010, is non-grandfathered and subject to the ACA requirements applicable to student health insurance plans under the final regulations."

Thanks.
The statements don't contradict because the issue is not simply whether or not the plan is grandfathered / non-grandfathered. The issue is that a health plan (even non-grandfathered) did not have to comply with the new ACA Preexisting reg until the first plan year beginning on or after January 1, 2014 as stated in the final regulations. If your plan is non-grandfathered then it only had to comply beginning with the first plan year beginning on or after January 1, 2014. I threw this out simply as a possible explanation. The only way to answer whether this applies is to ask the Plan Administrator what the plan year is.
 

lkc15507

Member
So, the insurance company has taken over 30 days to respond to my appeal. It is my understanding that this is a violation of the law. If that's correct, do I have a case to submit to an independent review board and win the appeal on that technicatliy that they have taken longer than 30 days to respond?
I can only speak to this in much generalized terms because there will be some variations—basically because of those same “GF / non-GF” as well as some other possible issues. (Your best source of specific appeal information will come from your plan book or website access.)

What you are appealing is a “post-service” claim and your plan may have (likely will have) up to 60 days to respond to a post-service claim on appeal. They may have even more time if they have notified you / your representative of any additional information required to complete the appeal.

Typically, to qualify for an independent external appeal you will need to exhaust your internal appeal process—likely one or two levels. Once exhausted, you may apply to file external appeal. The plan will determine if you are eligible to complete this review, but those requirements are fairly concrete such as whether or not you were covered by the plan at the time of service and whether or not the internal appeal process is complete. If determined that you do not qualify to file an external appeal then you can remedy any shortcomings of your appeal process and reapply--as long as you are within the time constraints applicable to you. You can file a suit at any time but a suit will probably not be successful until you complete all levels of available appeals including the external review.

Again, generally speaking, if a health plan violates the number of days allowed to respond to an adverse benefit determination on appeal, it’s not likely that it would result in a decision in favor of the appellant on that basis alone. Those types of minor violations usually have other remedies by filing complaints with the applicable regulating agency i.e. state department of insurance or federal department of labor.

Good Luck
 

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