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Insurance: HIV as a pre-existing condtion/payment denial
Feb 9, 2010

Dear The Body Expert... I have searched the database and believe my situation unique. Technically, I am self-employed. My company is located in Switzerland. Thus, I qualify as a freelancer living in New York City. I am HIV-positive, and until Dec.31, '09, purchased individual PPO insurance from Cigna. Cigna has since dropped individual plans. It was not until November '09 that I began new coverage with the Freelancers Union via Freelancers Insurance. My coverage level is PPO2. As I had not seen my doctor or taken medications since Dec. 2008, I was eager to visit my doctor, have full blood work done to ascertain T-cell levels and viral load (certainly increased from the excellent levels while on meds), and did so mid November. Important note: when filling out the group insurance application, I correctly and truthfully responded NO to all treatment/medication questions as relates to the 6-month period prior to application. Again, I had not received treatment or taken meds of any kind since Dec. '09. Now, the insurance provider is denying payment for the Nov. '09 office visit and lab bills (blood)and is requiring my doctor to provide my medical history. It is my understanding that the 'look back' period can only be up to 6-mths. The insurance provider is, so far, providing coverage for my three antiviral meds. My concern? That they will eventually refuse to pay for those meds. I am certain they find it odd that my doctor prescribed those meds for me the same day as my first visit in nearly a year, along with blood work. They do suspect a pre-existing condition, though I believe technically, according to the policy fine print, my HIV+ status exists beyond the 6-month prior-to-coverage rule. Does the above make sense? I gross $75,000 a year, and fear paying for these drugs on a monthly basis. I would also like to get blood work every three months, as recommended, somehow, someway, affordable, should the insurer deny me coverage, etc. Please advise!

Response from Ms. Franzoi

A health plan can have a look-back period of up to 12 months to determine what is a pre-existing condition. However, it sounds like your new plan might have a 6-month rather than a 12-month look-back so you should be okay. In the event that it does have a 12-month look-back and a 12-month pre-existing exclusion period, the plan would have to recognize your prior period of coverage under your CIGNA plan towards any pre-existing exclusion period provided that you did not have a significant break in coverage (defined as 63 days or more). So if you were covered under your CIGNA plan for at least 12 months prior to the November 2009 effective date, your new plan should recognmize that. Ask CIGNA for a Certificate of Creditable Coverage for you to provide to your new group health plan. Since the maximum exclusion period would be 12 months, depending on your period of prior coverage, whether or not you had a significant break in coverage and the terms of your new plan, you should be okay.

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