Pre-existing Conditions Law
Pre-existing condition laws are federal and state statutes designed, in effect, to limit American insurance companies' tendency to deny coverage to people who might "cost them money." It is not profitable for an insurance company to accept new applicants who are already sick or who are likely to get sick. It would be more profitable for the insurance company to simply keep collecting everyone's premiums and not have to pay out money to cover policyholders' medical expenses. That's why health insurance companies ask you whether you have any "pre-existing conditions" when you apply for health insurance.
Denial of Coverage Issues
Since insurers regard individuals with pre-existing medical conditions as greater liabilities and will often deny coverage completely or refuse to cover a pre-existing condition, the federal and state systems enacted pre-existing condition laws to help protect the health and well-being of the U.S. population.
Defining Pre-existing Conditions
The definition of a pre-existing condition varies from state to state and from policy to policy. In general, a pre-existing condition can be defined as any medical condition that a person had knowledge of, or had been treated for, prior to enrolling in a health insurance program. Under many pre-existing condition laws, a pre-existing condition is one for which any of the following was recommended or received within the six months prior to the health insurance enrollment date:
- medical advice
- diagnosis
- care, or
- treatment
The pre-existing condition could be almost anything — for example, heart disease, diabetes, cancer, carpal tunnel syndrome, a back problem, etc.
Exclusion for a Pre-existing Condition
This six-month period of time is known as the "look-back" period under pre-existing condition laws. The look-back period may be smaller than six months in insurance policies provided by large companies or with HMOs. Under most pre-existing condition laws, insurance coverage for person with a pre-existing condition can be denied for a maximum period of 12 months (18 for late enrollees).
There are also certain medical conditions that cannot be denied coverage under pre-existing condition laws, including pregnancy and conditions in children under 18 who have been adopted.
HIPPA Protections
A federal law, the Health Insurance Portability and Accountability Act (HIPPA), limits the amount of time and specific circumstances under which coverage for an individual with a pre-existing condition can be lawfully denied. HIPAA was put into effect in 1997 to allow American workers to move from one job to another without the risk of becoming uninsured because of health problems. In fact, HIPPA has provisions that:
- limit exclusions for preexisting conditions
- prohibit discrimination against workers and their dependents based on their health status; and
- guarantee renewability and availability of health insurance
State Pre-existing Condition Laws
Each state also has its own specific pre-existing condition laws that regulate the insurance industry, protect consumer rights, and provide a method of legal action for those who have suffered damages because of pre-existing condition law violations. If you have been wrongly denied health care coverage because of a pre-existing medical condition, you may be eligible to recover compensation for your losses. Contact us today to speak with an experienced and qualified attorney who can evaluate your case to determine your legal rights and options.
Be assured your matters will be in experienced & caring hands.
