Pre-Exising Coverage Denied for 10 Years!

[HowardC]

What is the name of your state?What is the name of your state? VIrginia
My fiancee, who is unemployed, used up her Cobra benefits and applied for individual health insurance. She was rather surprised to get a letter saying she is covered, except for her pre-existing hypertension, which won't be covered for 10 years! She has had no heart surgery or anything similiar, she is, like millions of others, simply on medications to lower her blood pressure. Can they do that?
I've been thinking that I am self-employed with my own individual HMO insurance - if I hire her, can I possible get the benefit of "employee" insurance in terms of the one year limit? None of their descriptive material stated anything about a 10 year restriction on pre-existing conditions. Maybe HMO coverage on her own might be better? Thanks.

 

[racer72]

Write your state representitives and push for a change in your state laws. My state has laws in place the prevent insurance companies from denying claims for lifestyle and hereditary medical conditions when changing insurance coverage. It's a bunch of BS when someone is forced to forego medical treatment due to circumstances beyond their control. But for your fiance, there is very little that can be done.

 

[cbg]

Howard, to answer your question I need to know the following:

1.) How long ago did her COBRA benefits expire?

2.) Is your plan a group plan or an individual plan?

(I understand that you are self-employed. I'm self-employed, too, but I have a group plan. It makes a difference to the answer.)

 

[HowardC]

Her coverage expired at the end of July. She was without any coverage until this "approval" came in a few days ago from the insurance company.

My plan is individual. I was thinking, maybe I could change it to a group plan, I don't know if two people is considered a "group." However, I have a feeling this could impact my SEP IRA which, although I"m not sure, only applies if I am the only employee. I guess another option is to get married and get a family instead of an individual policy, but that's a whole new subject

 

[cbg]

If yours is an individual plan, then not only does the protection I was thinking about not apply, but you would not be able to include her on it if you hired her. An individual plan is just that - individual. The pre-ex protection I had in mind only applies to group plans.

If you do decide to change it to a group plan and hire her, you'd better hurry. She has 62 days from the end of her COBRA plan to pick up another group plan if any pre-ex protection is going to apply. If she is not covered under another group plan 62 days after the last day she was covered under her COBRA benefits, the insurance carrier MAY (I do not say WILL - it's up to them) apply a pre-ex condition clause to her regardless of whether it is individual or group coverage. The difference is that if she becomes covered under a new group plan 63 days or more after the end of her COBRA, while they can apply a pre-ex clause, that pre-ex can only be for a maximum of 12 months. On an individual plan I don't know what the limits are, or even if there are limits.

Even if you married her and made her a dependent on your plan, she would still be subject to any pre-ex clause on your policy.

Keep in mind that just because one individual carrier gave her a 10-year limit on the pre-ex condition, doesn't mean that another one will do the same.

 

[HowardC]

I want to thank you very much for this information. It led me to to more research into HIPPA, and to call the Virginia Bureau of Insurance, and to call Kaiser Permanente. What I found out was that you correct re: her HIPPA eligibility, but the catch is, that if she applies for a HIPPA policy it will be much more expensive....under Kaiser, for example, up to 70% moe epensive. It sound like the car insurance pool for uninsurables. So I think we will apply to Kaiser (I am currently covered and I'm pretty satisfied) and see what their underwriters do in terms of pre-existing restrictions, I doubt they will be as severe. Thanks for your assistance, this forum and others here a great service to individuals.