Ankle excluded from coverage

by Guest » Sat Jan 07, 2012 03:16 pm
Guest

I am between jobs right now and I didn’t want to opt for COBRA coverage. I was financially stable enough to buy my own health insurance. I found a quote which was quiet good and immediately applied for it. A couple of days later the insurance company gets in touch and tells me that they want to exclude coverage for my left ankle. I had torn a ligament a couple of times when I was a kid and it’s been 20 years since the last incident. Now the underwriter tells me that any injury or disease of the ankle and the surrounding tissue will not be covered indefinitely. Although I know the ankle won’t be a problem in the years to come, is it worth taking the risk of leaving it uninsured? And is the torn ligament exclusion going to be added to my medical record and be counted when I choose to change my health plan again? Is it a better idea to use COBRA?

Total Comments: 5

Posted: Mon Jan 09, 2012 04:29 pm Post Subject:

COBRA is expensive and you’d have to pay the entire premium up front. If you can afford it, it’s not a bad option, although the exclusion has nothing to do with COBRA. The information about your ankle injury will be added to the Medical Information Board (MIB) and your present insurer has the right to contact your past insurer and look through your medical information. The waiver is a part of the contract you sign to have your application considered.

You can try and appeal against the exclusion and get a medical certificate to support it. You need to be certified by a registered orthopedic stating that the ankle injury is a non-issue and it won’t be the cause of any serious ailment in the coming years.

Posted: Tue Jan 10, 2012 06:25 am Post Subject:

You're speaking of pre-existing conditions, or "Pre-X" concerns. Pretty obvious what that means.

A lot of this depends on what state you reside in. Most states have pretty severe limitations in terms of what insurers can do regarding pre-x and coverage limitations.

So... I need to know the state that you're in.

Next is the potential for "creditable coverage" under HIPAA. It may not extend to your situation. What type of group plan did you have and when did your coverage under the plan (specifically) end? More on this later if it applies.

InsTeacher 8)

Posted: Tue Jan 10, 2012 03:58 pm Post Subject:

As far as I know, my company had me on a PPO plan and coverage ended 20 days ago since I was downsized. I am from Springfield, Illinois.

Posted: Tue Jan 10, 2012 10:55 pm Post Subject:

It doesn't sound as if the carrier is adhering to the pre-x rules in Illinois. Check this out:

The Minimum Definition of Pre-existing Illness or Condition
A pre-existing illness or pre-existing condition is an illness or condition for which:
• a licensed physician provided diagnosis, consultation, advice or treatment during the 24 months immediately before the effective date of the insured’s coverage.
• an initial diagnosis or treatment was received more than 24 months prior to the effective date of the insured’s coverage, but a licensed physician demonstrates that there is a reasonable medical question whether the illness or condition continued to a date within 24 months before the effective date of the insured’s coverage, without the need for further consultation, advice or treatment .
• clear, distinct symptoms of such illness or condition were displayed within 12
months prior to the effective date of the insured’s coverage, which in the opinion of a licensed physician would indicate that the illness or condition probably began and became observable before the insured’s effective date of the coverage; and o cause an ordinarily reasonable person to seek diagnosis, care or treatment.

The above definition is the minimum required. Any definition more favorable to the insured may be used. All policies that exclude the payment of claims due to pre-existing illnesses or conditions must define those terms.



In addition, since the passage of the PPACA (ObabaCare), there are programs in Illinois that, as of 1/1/12, will accept those with pre-x. The premiums aren't that bad. Here's a link to the site that has the info on the IPXP: Illinois Pre-Existing Condition Insurance Plan: http://insurance.illinois.gov/ipxp/

Finally, regarding Illinois law has the final say on pre-x: Illinois Administrative Code, Section 2005.30 The Minimum Definition of Pre-existing Illness or Pre-existing Condition. Here's the link to that specific page:
http://www.ilga.gov/commission/jcar/admincode/050/050020050000300R.html

InsTeacher 8)

Posted: Thu Jan 12, 2012 03:34 am Post Subject:

A preexisting condition may be excluded forever if it is singularly identified. However, in order to do that, the preexisting condition, as InsTeacher pointed out, must be one that has affected you in the past 24 months, specifically. In your case, it is an unfair denial of coverage.

My recommendation: if you believe the policy is reasonable in all other respects, accept it, pay for it, and immediately write a letter to the insurance company informing them that you dispute their classification of your ankle injury as a preexisting condition and will be filing a complaint with the IL dept of insurance. Send it Certified with Return Receipt Requested, and file the complaint. It should get someone's attention.

If not, and you later suffer an ankle injury, your lawyer will be able to use your documentation to win your case for unfair claims practices and unfair business practices.

---------------

Way to go DUCKS! :D

Add your comment

Image CAPTCHA
Enter the characters shown in the image.