Denial of enrollment for medical reasons?

[RLG]

Can baby with medical problems be denied enrollment in group health plan because he is a late enrollee and has a pre-existing condition? Parents tried to enroll baby in mother's plan after 30-day enrollment period for new dependents. Parents believed that baby was enrolled at birth after informing insurer of his birth by e-mail, but parents neglected to fill out form. Insurance company informed parents baby not enrolled when when baby was in hospital at Month 4; told parents NOT to fill out form and enroll him until after hospital stay, which lasted 5 weeks. Baby now 5 months old and insurance company denying enrollment based on late enrollee/pre-existing condition. Baby has certifiable coverage under spouse's plan that has reduced benefits that the parents have already exhausted.

Can mother's insurance company deny enrollment? If not, can they apply pre-existing condition exclusion? Mother is legal resident of Florida, lives/works overseas as USG contractor; insurance company based in Washington, D.C.

 

[cbg]

If the parents missed the 30 day window, then the carrier is entitled, and depending on the plan possibly obligated, to deny enrollment until the next open enrollment period. If the child is permitted to be late-enrolled and a pre-existing clause exists, the carrier may apply that clause.

 

[RLG]

Thank you. If the child is enrolled during next open enrollment, can the pre-existing condition clause be applied, or would proof of certifiable coverage apply?

 

[cbg]

The pre-existing clause can be appllied unless the parents are able to provide proof of previous coverage going back at least 12 months (unless your state has a lesser limit - my state limits the look back period to six months). However, what coverage there has been must be subtracted from the 12 months. For example, if the child had continuous coverage for five months, the pre-existing clause can only be applied for seven.