Insurance application denied......are these reasons even legal????

[Ladilee]

What is the name of your state? What is the name of your state? California


Hi all, I have a pretty serious question and I'm extremely upset, so I'll try to keep this short and to the point...thank you in advance for baring with me.

Okay, my son is 15 yrs old and since the age of 2 has been with blue cross and on their MRMIP program. Reason being...he got very ill at 13 months of age and ended up having some serious medical issues. We didn't know at the time but his insurance premium hadn't been paid on time, so when he got sick.... the insurance company wouldn't help us. We got him on MRMIP though and they've been helpful till now.
Recently we received a notice that they were graduating him from the program and that we had to choose another. I guess their new policy only allows MRMIP members to be insured for a certain amount of time and then they have to switch.

Anyway, we decided that because his 'medical' problems no longer exists and he's been taken off all medication and will no longer be seen by his neurologist, that we would try to get him on his fathers policy.

BC has made many mistakes with his application, mis-mailings, misstatements, etc… but we've jumped through every hoop they've asked us to. Last month we received a notice of denial because we marked on his application that he had been in speech therapy. (they asked, we told) We called them and asked what that had to do with anything medical, beings none of that was ever put through any type of insurance, that the school provided this service under F.A.P.E. They wanted a letter stating when he graduated from speech therapy, etc ... We did that.

Today we got another denial notice stating these reasons:

1. ongoing sinus polyp 9-24-03
2. new onset headache, "possibility migraine" 9-24-03
3. ongoing chronic seizure 9-24-03
4. ongoing learning disorder 9-24-03

His last appt. with his neurologist was on 9-24-03. At the appointment we discussed an incident 2 weeks prior in which my son had a major headache and I took him into the ER where they took an MRI to rule out tumor, I guess. They found a mass of polyps in his sinus. They wanted him to see an ENT, which we did 2 days later. The ENT, after examining him and getting his med history, said that he's had these polyps since he was a baby and they probably won't go away on their own, however, they aren't causing him any trouble and he can't say that the headache was caused by them.... because his face didn't hurt at all, and if the polyps were causing problems.... he'd feel it in his face when touched. He told us there was no reason to have them removed and that they were just 'there.' He said he could have had a migraine or it could have been heat exhaustion. (it was very hot that day and all the kids were playing pretty hard in the water).

This was discussed with his neurologist at his next appt, of course, and she agreed that the polyps have always been there and I didn't need to worry about them. I discuss many things with his neurologist, as he was only seen 2 times a year. I wanted her opinion on removing the polyps. She, of course, took notes as we spoke. That is where BC got their information…NOT from the attending doctor.

So anyway, the headache and polyp thing were one and the same appointment issue...but not according to the ins. comp.

As for the chronic seizures.... his last two EEGs were negative for seizure activity and he's been weaned off all meds completely...with NO adverse affects. He hasn't had a seizure since he was a baby! This information has been given to BC several times.

As for the learning disorder…and this one upsets me the most! What the heck does that (like speech therapy) have to do with anything? CAN THEY USE THAT AGAINST HIM?? It really seems unfair that because he's LD (mildly mind you...not that that should matter either) that they can deny him regular medical insurance. Nothing dealing with his LD has EVER been submitted for insurance payment...ever. He'll always be LD and they say that he must be "sign, symptom and/or treatment free" of all listed, for a consecutive 6 months for him to be considered. How is that possible and why should his learning trouble have a play in 'medical insurance issues? They certainly didn't try the "speech therapy" thing again…. but why is LD different? To me if feels very prejudicial, and in no way affects 'any' medical condition he's had, has, or will have in the future.

They also said that because these issues were even 'discussed' with a doctor, he's considered to 'have or suffer' from what ever was talked about. That's crazy. They never even asked for a report from the ENT specialist.... for a proper report about the headache or polyps. They just took their information from 'notes' taken by the neurologist at our last appt. Doesn't seem right/fair. He will see his neurologist one last time, in three months. She said she wants to see him and say goodbye because she won't need to see him again in the future…. he's epilepsy free/medication free and growing into a very medically sound young man. BUT, because of that last appointment, BC will consider him to 'have or suffer' from chronic seizures. ????? And we'll have to wait yet another 6 months to apply.

They've been stalling and sending silly reasons for denial for a long time, and each time, it's something different.... this time though it feels like a personal attack on my child for something he can not help and isn't, in any way, medically based.

Can they do this? What can I do, anything?

I apologize for the long post, but I felt some background would be necessary to understand what either BC or myself is saying. Please, if anyone has any advise I would really appreciate it. I'm finding it very difficult to believe that they can deny him on the basis of 'discussion notes' and even more infuriating… a learning disorder?!?


Thank you SO much for any comments or advise you can give me.
B.

 

[lkc15507]

ladilee:

Many things in your post leave me with questions. However, to get right to the point--and this won't be well received--the reasons given to you for denying coverage to your son, by the father's plan are perfectly legal. They can do this--assuming they are properly applying enrollment / eligibility requirements as set forth in the written plan document. There are VERY few medical conditions / procedures that have any mandated coverage at all. Even then, one must be properly eligible / enrolled in a plan in the first place.

Insurance carriers try to minimize risk. Your son's past medical history demonstrates supplying coverage to him as a poor risk. The private plan you are trying to enroll him in likely states that "any care or treatment" (this would include simple physician checkup or follow-up) within a specified period of time will be considered with his application. To address one of the issues you brought up, the speech therapy, I will give this explanation. Even though the therapy has been supplied through the school, it is entirely possible that the private insurer could be responsible for payment of this therapy should they provide him coverage. There is a federal statute that states that (much paraphrased) the availability of these types of services through a school program does not relieve an insurer from providing the service if they are obligated to do so in the first place. In other words, depending on the exact diagnoses and wording of the plan, the insurer could be "on the hook" upon enrolling your son into the plan. That is why the insurer would consider the speech therapy / learning disability when making their determination.

Now, on to other things. The wording of your post makes me question whether this is an actual denial of enrollment into the plan based on Evidence of Insurability or if these are Pre-existing Condition determinations being applied. Private plans will have very specific enrollment requirements. Federal law--HIPAA--allows one to change plans without the application of Pre-existing conditions or Evidence of Insurability if done timely--I.E. if one can demonstrate Creditable Coverage without a break of 63 days or more in that coverage. Although I know virtually nothing of CA's Medicaid laws, I suspect that the plan he was under would be considered Creditable Coverage . Since he is now being denied (or pre-ex applied) I suspect there is a timely enrollment issue here.

First I suggest checking out sources for information on timely enrollment, pre-existing conditions, evidence of insurability, open enrollment, late enrollment, and qualifying events. The summary plan document of the plan you are applying to and www.dol.gov (Department of Labor) are going to be the best places to start. Try to get a feel for those things first, then if you need to, post back with information regarding when coverage ended for your son under the BC / BS plan, when is (if there is) open enrollment under employer plan, when applied etc. Specific dates would be the key.

In a nutshell, if your son was not properly / timely enrolled in the employer plan when / if eligible, you will not be successful based on medical conditions (Evidence of Insurability). If this is a Pre-existing Condition issue, enroll him anyway. The pre-ex condition limitation is time limited and would eventually be covered. Also, below is a link to your state's MRMIP program. It seems that they may still be able to provide some relief. Lastly, if your state's Medicaid program dropped the ball, causing late enrollment into a private plan, I have seen situations which were successfully appealed, and the private plan had to allow enrollment. (Government is likely to be successful cost-shifting to a private plan everytime.)

http://www.hmohelp.ca.gov/coverage/mrmip/

I hope this gives you some place to start in assuring that you get proper coverage for your son. However, be very aware that timely enrollment issues are tough to beat. This is a very complicated subject and my answer is very general. Again, specific dates and information regarding his father's plan would be very helpful. I wish you the best.

lkc15507