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What is Going On With Health Insurance Exclusions
Nov 20, 2000

I have been reading several questions on here asking whether an employer's health plan (whether it be a insured group plan or a self-insured plan) can legally exclude coverage for certain illnesses, like HIV, and/or cap benefit amounts for HIV. Am I missing something here? Isn't this discrimination under the ADA? The EEOC Guildelines for the ADA say that an employer can't do this, unless he makes similar caps for ALL disabilities. I do know of a couple of court of appeals cases that permitted a private insurer to cap benefits, but that was not an employer plan (i.e, the plaintiffs argued it was discrimination under Title III of the ADA). It seems to me that if an employer discriminates by providing certain employment benefits to one group of individuals but not to individuals with certain disabilities, this is discrimination under the ADA. What is going on? Please answer this question for me. The only thing I can think of is that employers or insurers are claiming that insuring HIV is an "undue hardship" under the ADA, and therefore the employers and insurance company can cap the benefits. But, I would imagine a court would look at this with close scrutiny.

Response from Ms. Franzoi

It is allowable for health plans to put in caps and/or exclusions on coverage.

Lynn L. Franzoi



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