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Follow-up on Long Term Care Question
Jan 24, 2006

Hello Ms. Franzoi,

Below is my original question w/your response. I have a follow-up question. You mention in your response that if I have not been seen by a physician for anything related to my HIV status within the 6 months prior to the effective date of the coverage, I would not have to disclose my HIV status. My question back to you is, would I qualify as not being seen? If. My last actual blood work and office visit was Aug 05' and I had my next blood done again in early Nov. 05 (but didn't have an office appointment, the Dr. called me with my numbers) Therefore is my Nov. blood work without an office visit constitute "being seen"? (I know this being technical but..). My "buy up" is coming up the first week of March and I would obviously like to take advantage of the buy up if possible. (In a nut shell I guess Im asking whats the definition of being seen?)

Thank you!!!


Long Term Care/Pre-existing Nov 22, 2005

Hello! And thank you very much for taking the time to answer my question. As an employee of my large company, I may purchase additional Long Term Care coverage during the enrollment period without having to fill out a medical questionnaire as long as I dont exceed the Guarantee issue limits. (Currently the company pays for my Long Term Care coverage, which has a $2,000 benefit for 3 years at no cost to me. With the new options on the table I can increase my coverage to $7,000 per month for 3 years). The new coverage being offered states that Benefits may be subject to a pre-existing condition exclusion. Their definition of Pre-existing is as follows:

Pre-existing condition is a condition for which medical advice or treatment was recommended by, or received from a provider of health care services, during the six months period right before coverage begins.

It goes on to say:

The policy will cover Pre-existing conditions that are disclosed on the application no later than six months following the effective date of the coverage, regardless of the date the loss or confinement begins.

Just so you know a little bit about my background and employment history. Im a 36 year old male that has been HIV positive close to fourteen years and Im not on Meds as of yet. I have been with the same company a little over 10 years and was diagnosed during this same time frame.

The extra premium wouldnt be a burden whatsoever. However I would only want to pursue the extra coverage if it were not to exclude my pre-existing condition. By the language I used above what would your advice be on my eligibility?

Many Thanks!

Response from Ms. Franzoi

Based on how you describe your plan and the buy up option, if you haven't taken any meds or sought medical treatment or seen a physician for anything related to your HIV status in the 6 months prior to the effective date of the coverage, you would not have to disclose your HIV status. For example, if you tested positive 3 years ago but are not currently on meds or seeing a doctor for HIV and haven't done so in the prior 6 months, your HIV status would not be a pre-existing condition as defined in the plan.

Response from Ms. Franzoi

I apologize if I didn't make my self clear in my first reply. Let me try to explain this in a better way. Most insurance plans have some language that defines what is considered a pre-exisiting condition. This language often refers to taking medication for a particular condition, seeing a doctor for it or having labwork done, etc. The definition of a pre-existing condition can vary by insurance contract. In addition, many plans will ask if you currently have or have ever been diagnosed as having a specific medical condtion such as high blood pressure, high cholesterol, being HIV+, diabetes, asthma, etc. Answering yes to any of these could also be deemed a pre-existing condition, even if you have the condition under control. For example, I know of an individual who had knee surgery 3 years prior to applying for a long term disability policy. Although the surgery was successful and he was no longer in physical therapy and had resumed an active life, the insurance company denied him long term disability coverage because of his former knee surgery. In your case, the fact that you go in for periodic labwork and receive your numbers from your doctor, whether or not you actually see him for an office visit, would probably impact your ability to increase your coverage. Periodic visits to a doctor or getting blood work would usually be considered seeking treatment for a medical condition. I am not an underwriter but I think having labwork done in November to monitor your numbers would be considered "treatment," i.e., monitoring your HIV status. In addition, depending on the medical questionnaire, the fact that you are HIV+ (assuming the question is asked) would result in the insurance company classifying you as having a pre-exisiting condition and they might not issue you the increased coverage.

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