Cancelled coverage during care

[Radman2]

My son had extensive knee surgery in December which caused him to have to withdraw from college during recovery and rehab. The physical therapy and rehab were protracted and only partially successful initially. He underwent a manipulation of the knee under anesthesia in mid June followed up by 2-3 additional weeks of therapy. He is now scheduled for a 6 month followup with the surgeon. He returned to college for the fall semester. My health insurance asked for proof of enrollment for the fall semester. Due to course availability he enrolled for 6 semester hours and was considered part time. The insurance carrier called in October to question the hours. The caller said that he could no longer be covered on my policy. I immediately moved to acquire insurance from another carrier and was able to have it effective November 1. I have never received a written notice of ineligibility. Today, I received EOB letters denying payment for physician charges and the therapy performed in June.

Is it legal to cut off coverage without a written (formal) notice of cancellation and is it legal to deny payment on services that were necessary to complete care for the previous surgery?

 

[cbg]

If your son no longer fits the definition of eligibility, then the insurer does not have to cover him. I'm not sure about written notice of cancellation; that may be a state thing. But I think an argument can be made that if you have a copy of the SPD, which spells out who is and is not covered and when (they're usually pretty specific about this) you can be considered to have been notified. Obviously I don't know if that is the case here.

If the individual is no longer covered, nothing in the law requires the insurer to continue to pay for medical care, even if the course of treatment began when he was still covered and even if the treatment is medically necessary. There may be some contractual exceptions to this, but if they applied here, you wouldn't be posting the question.