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M W | Insurer denied benefits for preexisting condition...? |
My wife (a teacher) recently started a new job and joined a group health plan. Before she started, she had health insurance continuously with her parents right up until the time she started as a teacher.
But the insurer denied benefits for a recent doctor's visit, citing the preexisting condition clause. When we told the insurer about the other coverage, they said "they don't do that." Is this illegal under HIPPA? |
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Lisa A
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That has nothing to do with HIPA. It's COBRA that you are looking for. Have your wife get a copy of her certificate of coverage from her previous insurance. Fax it to the new insurance. Read up on COBRA so that you are well informed, and start arguing with the new insurance. You are in the right if your wife's insurance truly never lapsed and she was covered for the previous 18 months. |
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Club_obi_wan
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Contact your previous carrier and request a certificate of creditable coverage. When you receive the certificate you'll need to send it to the new carrier - it should be enough to have the waiting periods waived. I'd suggest contacting your current carrier again and ask them to specifically explain the waiting period/pre existing contition clause on your policy. Tell them that your old carrier is sending you a certificate and ask how you can go about sending it to them.
Be sure to get the full name and extension of the individual you speak to and continue to deal with that person if they sound competent (the person you mention above was either stupid, lazy, not paying attention or all of the above). Once your certificate is received they should waive the waiting periods then you'll need to ask for the claim to be reprocessed.
Be sure that the service provided is something that is not specifically excluded on her policy.
Keep in mind that there are circumstances where the transfer of coverage will not be accepted, if there was a break in coverage that can cause problems, there are other circumstances too, but that was a previous life of mine (insurance customer service....my first job out of college!) |
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Suzanne: YPA
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Yes, this is illegal provided your wife had sufficient creditable coverage to negate the plan's pre-existing condition exclusionary period. HIPAA portability applies to ALL types of plans, whether they are fully-insured, self-funded ERISA plans, or self-funded government (non-ERISA) plans.
What you need to do first is send the insurer a written appeal and enclose a copy of your wife's "Certificate of Creditable Coverage." The insurer will render an appeal decision; if it's not favorable to you, have her send a written appeal to your state insurance commissioner's office. While HIPAA is a federal law, states have the authority to enforce these provisions because they regulate insurers.
If the plan is self-funded, however, your insurance commissioner can't help. In that case, if you receive a negative appeal decision, contact the United States Department of Labor by calling 1-866-4-USA-DOL.
EDIT: To "Kimmie," the break cannot be more than 63 days. Waiting periods aren't counted against the lapse period.
To "Lisa" and "Zippy," HIPAA contains TWO separate provisions: the portability provision (which is what we're discussing here) AND the privacy rules, which is what you're both referring to. HIPAA is much more than just privacy rules. In fact, the portability provision kicked in during Pres. Clinton (who passed the law) and the privacy rules were finalized under Pres. Bush #2. |
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hightechchic
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If your wife had continuous, creditable (and there's a key word) coverage with less than a 63-day gap (and at least 12 months of coverage) then she cannot be denied coverage for her pre-existing condition.
However, there is a possibility that her previous insurance is NOT considered creditable coverage. For instance, if she had what's often referred to as an "open enrollment" policy, this would NOT count toward satisfying the creditable coverage requirements.
She will need to obtain a copy of proof of prior insurance from her former insurance company and submit it to the current company. They will respond in writing -- if you don't understand the response, call them immediately. The longer it goes on, the more of a mess it will be. |
|
es
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The first thing she must do is ask for a review of the decision, in writing. The second thing she should do is ask her old insurer for a certificate of eligibility. The third thing she should do is call her teacher's union, and ask for help with this. When a new employee starts under a business plan, there is not supposed to be any underwriting, or pre-existing conditions. If all else fails, report the insurer to the state insurance department. |
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zippythejessi
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Lisa is right. HIPAA has only to do with patient privacy and the release of information.
As long as your wife get a copy of the certificate of coverage from her previous insurance (it's often just a letter stating the plan was effective from until whenever it termed) and she provides a copy of it to the current insurance and asks them to reconsider the claim, they should waive the pre-existing clause. Especially if her previous insurance ended immedately before the current one began. |
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Kimmie
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It is HIPAA that covers this and if she was continually covered in the months prior to her new coverage (no break in coverage over 30 days I think) then they can't push a pre-existing condition clause. The only way they can do that is if they ASKED her about it prior to her getting the coverage and she told them she had been seen previously for this "condition" and THEN they can consider it pre-existing. |
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