Preexisting conditions and switching Insurance Companies

[tfennc]

I kept my health Insurance for the 6 months allowed after leaving my former employer. At the time I had a preexisting condition and my understanding was that this condition would be covered under a new policy. I was offered a rider for my condition excluding coverage for 4 years. Now, I am being told by informed sources that my condition should have been covered and that 18 months is the legal limit for COBRA continuation. My insurance salesman repeadly told me only 6 months. I live in South Carolina. Any help would be greatly appreciated.

 

[cbg]

COBRA is for 18 months minimum. However, if you have had continuous health insurance without a break of 63 days or more, any preexisting conditions should be covered.

You refer to an insurance salesman; was this a private policy instead of a group plan?

 

[tfennc]

Yes, it was a new, personal policy with Fortis (my previous coverage was with John Alden and Fortis is the parent company to John Alden) outside of what was offered at my new employer. I did not have a break between policies.

I was diagnosed ,through MRI's, of degenerative discs in my neck while with John Alden. During the last remaining week of what I thought was the limit to my COBRA, and while in the process of signing up with a new policy, I was left with the realization (told by my salesman) that my condition would probably not be covered.

I did sign a rider- does this mean I have no recourse?

Why was I told by John Alden my coverage was ending after only 6 months of COBRA?

Do you think I should have a lawyer look into this. I am in serious shape and need treatment but cannot afford the surgery.

 

[cbg]

I have no idea why Alden told you that, unless it was to get you to drop the COBRA in favor of his plan.

WHen you say you had a rider, are you talking about a rider that covered this condition, or one that acknowledged that it would not be covered?

Are you still on the Alden plan, or are you now on a group plan?

Has your existing coverage, whichever it is, already denied treatment on the basis of pre-existing, or are you assuming?

If you can answer these question for me I can probably point you in the right direction. You may not need a lawyer.

 

[tfennc]

I have learned that the continuance of coverage in SC for me would have been 6 months since my employer had under 20 full- time employees.

The rider would be for the current (Fortis) policy- there was not rider under the previous (John Alden) policy.

I am not on a group plan presently. I was not told the advantages of a new group policy vs. individual with HIPAA laws.
It would have been too easy for both reps. to have revealed the benefits of staying with a group plan, which was offered by my employer. My Fortis rep. told me I would be better off with an individual policy I could use as bargaining tool for my new and future employers.

My existing coverage, which issued a rider for pre-existing has denied treatments.

 

[cbg]

Okay, the under-20 thing is important and I should have caught that. Technically, then, that was not COBRA, but state continuation. It amounts to the same thing in terms of the coverage, but it's important for the reasons we just discovered; it makes a big difference in terms of the definitions.

Here's another very important thing to consider; it is possible for the CONDITION to be covered, but for the specific treatment you (or your doctor) wants, to be not covered under the plan. Just because the treatment was denied does NOT mean, just of itself, that they are calling the condition pre-existing (unless, of course, they told you that they are.)

Here's the deal. If I am understanding you correctly, you have access to a group health insurance policy from your employer, but your Fortis salesman convinced you not to take it. While I'm not blaming you for believing him, that was a sales trick. As an employer, I can tell you that whether an employee has their own insurance or not makes no difference to me in the least. Sure, it's cheaper for me if he does, but he won't get a higher salary or a bigger bonus package by virtue of the fact that he's not taking the benefits. No leverage there.

You need to find out, first, when is the next open enrollment period. You want to join the group health plan at an open enrollment period if at all possible, even if they'll let you on sooner, which they may or may not be able to do.

Also you want to find out whether the treatment you want is even covered. As I said above, even if the condition is not considered pre-existing, it does not follow that every possible treatment for the condition is automatically a covered benefit under the plan.

Here's why I'm pointing you this way. It is to your benefit to get onto a group plan. You do not want to go onto another individual plan, because HIPAA does not apply when you go from one individual plan to another individual plan. It does count if you go from a group plan to a group plan, or an individual plan to a group plan.

Once on the group plan, any creditable coverage you have had before will be counted. That will include the time on your current individual plan and also the state continuation coverage. If you have been covered on some creditable policy for 12 months or more, with no gap in coverage for 63 days or longer, they CANNOT count any condition as pre-existing. If you have a 63 day or longer gap, or if you had less than 12 months creditable coverage, the maxiumum length of time your condition can be considered pre-ex will be the difference of your creditiable coverage and 12 months; so for example, if you had eight months of creditable coverage, the maximum they can consider a condition pre-ex is 4 months.

Clear as mud?

 

[tfennc]

Some Factors: I'm no longer with the employer offering the group plan- but, that doesn't mean I couldn't join a group plan with, say... the chamber of commerce, musicians federation... does it?

"Special Exception Rider- It is hereby understood and agreed that the Certificate to which this rider is attached is amended to provide that the policy does not cover anything of which: Herniated, bulging, ruptured disc or degenerative disc disease, including any diagnostic procedures, treatment, surgery or complications thereof." "Removal of this rider is not automatic, but will be considered upon request after 01-01-04.

The 'pre-existing condition' part- i'm having some confusion with. I never declared a PEC. nor was I told I have a PEC- I'm just using it because that's what I call it- I was being treated (had MRI's, pain medication, occassional Dr.s visits for pain...) during the time I was with John Alden. I did declare all this on my application to Fortis. The cause or emergence of the condition happend within the time I was already under John Alden coverage, and not before that time.

At no time within the last 15 years have I NOT been covered under creditable group coverage. As of Jan 1, 2002, I will have been covered 1 full year under a individual policy. If I go back to a group plan, you're saying that I could possible not have a rider or have my condition called, 'pre-existing?'

Thank you so much for your kind assistance.

 

[cbg]

Yes, that's what I'm saying. Since HIPAA was passed in, I think, 1996, riders on group policies have been exceedingly rare, and pre-ex is extremely limited. Under any circumstances whatsoever, the longest possible time a group policy can call a condition pre-existing is 18 months, and that is for someone with no creditable coverage who joins as a late enrollee. Someone who has 12 months or more of creditable coverage and joins the plan when they first are eligible or under a qualifying event would have no pre-ex at all. This is the law.

You must keep in mind that just because a condition is covered does NOT mean that any kind of treatment you want for it is automatically covered. I don't want you to get the idea that you can join a group plan and the surgery is covered no questions asked. You will still be bound by the limits of the policy. But it is no longer the case that someone can be excluded from treatment on a pre-existing condition forever, at least for group plans.

 

[tfennc]

Thank you very much for the time spent helping me with this. I will apply for group coverage under our chamber of commerce policy and see what results.

Any general advice to offer and advice as to answering underwriting questions?

I have never been treated whatsoever for my condition other than occassional Dr. visits for pain med.