pre-existing condition

[dsjscharold]

What is the name of your state? Ky.
I thought the laws had changed in our state several years ago regarding pre-existing conditions. We just prescribed for a new health insurance carrier starting Aug. 15. But since my son had a scope done on his knee this past February (the Dr. fixed nothing) the insurance is saying it is pre-existing and will not cover any expenses now that he is having problems again with this knee. Can they do this?
Thank you.

 

[Beth3]

I don't know about state law on this but federal law changed a few years ago. If you went directly from one insurance plan to another with no lapse in coverage, pre-existing conditions limitations should not apply.

The applicable law is HIPAA - Health Insurance Portability and Accountability Act.

HIPAA limits a health insurer's ability to impose preexisting condition exclusions to conditions treated or for which medical advice has been sought to a 6-month period prior to enrolling in the new plan and limits the pre-x exclusion period to no more than 12 months. Additionally, the 6-month period must be reduced by the number of days the employee or dependent had other health care coverage (called "days of creditable coverage") unless there is a break in coverage of 63 days or longer between participation in the plans.

So, for example, if your son was covered under another plan for 12 months and then was enrolled in this one within 63 days of the former coverage ending, the new carrier could not impose any pre-x limitations.

Hope this helps. If you need more information, an internet search on HIPAA should get you what you need.

 

[CIAA]

dsjscharold,

HIPAA only applies if you are moving from one group health policy to another group health policy.

If you are not changing groups, then the answer to your question is going to lie in the specific policy wording and the specifics of the medical condition. You can usually assume the policy language is in compliance, although we can check it for you if you want to quote it to us.

As mentioned, the other thing is the specifics of the medical situation. For example, if you have a partial tear in the knee and subsequent activity results in a complete tear, it's not pre-existing. Often, the causation or proximate cause of the loss is not "pre-existing" and benefits may be payable even though it may have aggrevated a pre-existing condition.

Hope this helps