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A Cut, A Hospital, Insurance, and my Job
Sep 1, 2006

I had a low risk encounter that involved having a cut on my finger. Two days later, I grew worried, whether this could possibly lead to me contracting HIV. I went to the emergency room of the local hospital. The doctor sent one of the residents who saw it, said, "don't worry about it this is low risk" and gave me a list of places I could get tested.

Naturally, I made it a point to keep this as low-profile as possible. I said that I was not going to give my Social Security Number and pay for it myself. I told them that I did not want it reported to my insurance. They charged my credit card for the full amount. Later, I did go to a clinic and got tested negative - at 6 weeks, I am still waiting for my 3 month test. Now, two months later I received a letter from my insurance company that I might have to pay x amount to the hospital. The amount is not my concern. But, I would greatly appreciate it if you let me know:

(1) Did they violate my privacy, by telling my insurance about something that I had already paid for on my own?

(2) Have they double charged - first me and insurance co later?

(3) How can I go about finding what they have on file - i.e. if it is just reported as a cut or as an HIV related thing? Can I get the incident deleted from my insurance companies record?

(4) I am changing my job in a month and will be covered by another group policy then. Will the new insurance co be able to look this incident and what can they do? (5) If God forbid, I am not negative, will this incident being on the record - make it pre-existing condition and can the new insurer deny my benefits?

(5a) Can my future employer find out about this?

Please let me know. I will be very grateful as this has all kinds of implications for my job change. Thank you!

Response from Ms. Franzoi

(1) Since the hospital either had your health plan information on file or received it from you at the time of the ER visit, it would just be standard procedure for them to bill the insurance company. I don't think this would be considered a violation of privacy, just standard billing practices. Their submission should've indicated that you had paid for the procedure so that the insurance company would reimburse you not the hospital.

(2) If the insurance company reimburses the hospital, the hospital must reimburse you. Your Explanation of Benefits from the insurance company will tell you whether or not they paid the hospital directly.

(3) I don't think there is any way to remove this incident from your medical records or the insurance company file. You could request a copy of the claims submission from the hospital. It is probably a form that has many ICD-9 codes on it and the hospital checked the ones associated with an ER visit, a finger laceration, etc. There usually are no "notes" on this form unless there is a diagnosis.

(4) If you are changing jobs, as long as you enroll in your new health plan during the initial enrollment period, there would be no reason for the new health plan to look at prior health records. If you have a claim that appears to be from an illness that you had prior to coverage commencing and your new health plan has a pre-existing condition clause, your new health plan might request prior information. However, if the new plan has a pre-existing exclusion clause and you can prove that you had been covered for at least 12 months under your prior plan, the new plan cannot impose this clause on you. You should request a Certificate of Creditable Coverage from your current health plan.

(5) Please see my response to question 4. Not all health plans have pre-existing exclusion clauses. Even if your new plan does, it cannot impose this exclusion for a period greater than 12 months and it must count your period of Creditable Coverage under your prior plan towards this, unless you have a break in coverage that is greater than 63 days.

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