Jul 18, 2005
I am unclear about the pre-existing condition clause. If you test HIV positive before the open enrollment period of a future employer: 1. Can you be denied any coverage at the time of open enrollment? 2. Can your future insurance provider refuse to pay for any infections or medications that are HIV related? I am in a name based reporting state and fear that no future illnesses would be covered if I am documented as HIV positive before I start a job.
Response from Ms. Franzoi
A pre-existing condition clause is an exclusion for treatment for a particular health condition for a period of time (usually 12 months) because you had the condition and received treatment for it during a period of time (usually 90 days) prior to coverage commencing. It applies when you initially apply for coverage not during open enrollment. Pre-exisitng condition clauses are governed by federal law (HIPAA). Under HIPAA, a group health plan cannot have a pre-exisitng condition exclusion period for longer than 12 months. This means that the longest time treatment for a particular condition can be excluded is 12 months. Furthermore, if a plan has a pre-existing exclusion clause, it must recognize prior periods of health coverage towards this exclusion unless you had a break in coverage of greater than 63 days.
In your case, if you were to become covered under a new plan (because you changed jobs not due to open enrollment) that had a pre-existing condition clause, it would not apply to you if you had been covered under another plan for at least 12 months and had not had a break in coverage of greater than 63 days. A pre-existing condition clause only applies to the medical condition that is considered pre-exsiting not to other illnesses.
INSURANCE PLEASE HELP
This forum is designed for educational purposes only, and experts are not rendering medical, mental health, legal or other professional advice or services. If you have or suspect you may have a medical, mental health, legal or other problem that requires advice, consult your own caregiver, attorney or other qualified professional.
Experts appearing on this page are independent and are solely responsible for editing and fact-checking their material. Neither TheBody.com nor any advertiser is the publisher or speaker of posted visitors' questions or the experts' material.