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Of Employment, Insurance, and Preexisting Conditions

1ddqd1ddqd Registered User regular
edited February 2010 in Help / Advice Forum
My g/f recently switched jobs and is now contract-for-hire with this new company. Her new job has no health coverage until she's fully hired, so we bought insurance through UnitedHealthcare (the same provider she had at her previous job under her employer's group policy.

Now, she's made an appointment to see a urologist because her sides are hurting and all other tests came back negative (except for the urine test, which had trace amounts of blood).

Doctor stuff aside, UnitedHealthcare now says she has a pre-existing condition. The break in coverage was less than 1 month (quit on 1/15, bought coverage 2/10). I remember reading an actual LAW that says pre existing conditions must be covered as long as the gap in coverage was less than 60 days, but now I can't find it. UH is saying they can't do anything.

Now she's stuck with no chance for a diagnosis (we're dirt poor) and coverage that doesn't do shit for her.

1ddqd on

Posts

  • DeebaserDeebaser on my way to work in a suit and a tie Ahhhh...come on fucking guyRegistered User regular
    edited February 2010
    Call United and tell them that you are covered under HIPAA. They'll tell you where to send your appeal letter which you should do immediately.

    Deebaser on
  • DeebaserDeebaser on my way to work in a suit and a tie Ahhhh...come on fucking guyRegistered User regular
    edited February 2010
    oh and contact the old insurer for proof of 'creditable coverage'. this shows that she had coverage for the amount of time where new health insurer can't play bullshit pre-existing condition games and that furthermore UHN can eat a dick.

    Deebaser on
  • benholiobenholio Registered User regular
    edited February 2010
    Call the previous insurance company and ask them for a Letter of Continuous Coverage. It will have the dates that she started and ended her previous policy. You'll need to send that to the new insurance company and they will fix everything on their end.

    benholio on
  • 1ddqd1ddqd Registered User regular
    edited February 2010
    The previous company is the same damn company, you're telling me databases aren't connected with a damn primary key? Fucking bullshit. And yes, I told her all of that, just needed to vent

    1ddqd on
  • DeebaserDeebaser on my way to work in a suit and a tie Ahhhh...come on fucking guyRegistered User regular
    edited February 2010
    Well speaking as a former data guy for a health insurance company, member demographics don't matter worth fuck all to them. They don't care that Jane Smith (SS# 123-45-6789) that they insured as an employee with Company A is the same Jane Smith (SS# 123-45-6789) that just submitted an application for an individual policy that roughly coincides with the termination of Jane Smith (SS# 123-45-6789).

    The way their data reads it is that Employer Group 12345 terminated member X2345-01 from benefit group A. In unrelated news, some scrub bought an individual policy. Let's deny her shit because, well, fuck her, that's why.

    Deebaser on
  • The Crowing OneThe Crowing One Registered User regular
    edited February 2010
    1ddqd wrote: »
    The previous company is the same damn company, you're telling me databases aren't connected with a damn primary key? Fucking bullshit. And yes, I told her all of that, just needed to vent

    You'd be immensely surprised at what large corporations can't do.

    Departments don't talk to each other. In other news you're on your own to provide proof, even if that proof comes from a different department in the company who is being proven to.

    The Crowing One on
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  • 1ddqd1ddqd Registered User regular
    edited February 2010
    They're telling her its a clause meant for group-to-group policy changes and since the insurance we bought is individual she doesn't qualify for that exemption.

    WTF. This whole industry can kiss my fucking ass.

    1ddqd on
  • XaquinXaquin Right behind you!Registered User regular
    edited February 2010
    call your local health dept. and they may be able to assist her. Medicare (once we found out we qualified for) wasn't too difficult to get.

    Xaquin on
  • XaquinXaquin Right behind you!Registered User regular
    edited February 2010
    what state do you live in?

    Xaquin on
  • DeebaserDeebaser on my way to work in a suit and a tie Ahhhh...come on fucking guyRegistered User regular
    edited February 2010
    They're wrong. Very wrong. As long as your application was truthful and contained full disclosure (assuming you're in a bullshit medical underwriting state), they can not exclude things they deem 'pre-existing conditions' if she held continuous coverage over a certain amount of time.

    Ask for a supervisor and the address for their appeals department. Let them know that you're CCing your state's Department of Insurance as well as your state's Attorney General. (Writing your congressman and CCing the CEO of the Health Insurance company should also be included as optionals. I wouldn't mention it to the phone dude as it makes you sound like a lunatic.)

    This will garauntee the shortest turn around time possible. :)

    Deebaser on
  • 1ddqd1ddqd Registered User regular
    edited February 2010
    We're in TX. How long does the appeals process take? I'm so fucking livid at the whole situation.

    1ddqd on
  • DeebaserDeebaser on my way to work in a suit and a tie Ahhhh...come on fucking guyRegistered User regular
    edited February 2010
    I don't know texas state regs, but in NY its up to 30 days. Try to file an appeal over the phone with the phone monkey's supervisor, but I'd file paper certified mail as well. Recorded phone calls can be 'lost' and they're the only ones with the recording.

    Deebaser on
  • 1ddqd1ddqd Registered User regular
    edited February 2010
    Ok, so I went to work and couldn't check back, but here's what we're doing. Since her previous employer's coverage can be extended, even though it's more expensive, it's still a group policy, so we're cancelling the UnitedHealthcare individual policy and changing back to the original one. It's more expensive but she won't be considered a pre-existing condition.

    This whole thing has brought home to me just how fucked the industry is.

    I was for health care reform before, but now I'm absolutely behind it. Fucking rediculous. This whole thing had her in tears. She asked, with tears streaming down her face "I don't get it, if I want coverage and I'm willing to pay, why won't they cover me?"

    It was heartbreaking knowing what she was feeling (considering what she's been going through). I was literally | | <---that close to going down to the court and getting eloped so she'd have coverage through mine.

    1ddqd on
  • WileyWiley In the dirt.Registered User regular
    edited February 2010
    Deebaser wrote: »
    Well speaking as a former data guy for a health insurance company, member demographics don't matter worth fuck all to them. They don't care that Jane Smith (SS# 123-45-6789) that they insured as an employee with Company A is the same Jane Smith (SS# 123-45-6789) that just submitted an application for an individual policy that roughly coincides with the termination of Jane Smith (SS# 123-45-6789).

    The way their data reads it is that Employer Group 12345 terminated member X2345-01 from benefit group A. In unrelated news, some scrub bought an individual policy. Let's deny her shit because, well, fuck her, that's why.

    Also, its a percentage game for them. They deny based on pre-existing conditions for ten people who are actually covered and maybe only seven or eight follow up with an appeal. So two or three people they would have had to pay out for but didn't because they didn't follow up with a couple phone calls saves them a few grand.

    Wiley on
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  • FeralFeral MEMETICHARIZARD interior crocodile alligator ⇔ ǝɹʇɐǝɥʇ ǝᴉʌoɯ ʇǝloɹʌǝɥɔ ɐ ǝʌᴉɹp ᴉRegistered User regular
    edited February 2010
    1ddqd wrote: »
    Ok, so I went to work and couldn't check back, but here's what we're doing. Since her previous employer's coverage can be extended, even though it's more expensive, it's still a group policy, so we're cancelling the UnitedHealthcare individual policy and changing back to the original one. It's more expensive but she won't be considered a pre-existing condition.

    This is probably unnecessary. did you take Deebaser's advice here?
    Deebaser wrote:
    Ask for a supervisor and the address for their appeals department. Let them know that you're CCing your state's Department of Insurance as well as your state's Attorney General. (Writing your congressman and CCing the CEO of the Health Insurance company should also be included as optionals. I wouldn't mention it to the phone dude as it makes you sound like a lunatic.)

    Because this is good advice.

    Feral on
    every person who doesn't like an acquired taste always seems to think everyone who likes it is faking it. it should be an official fallacy.

    the "no true scotch man" fallacy.
  • DeebaserDeebaser on my way to work in a suit and a tie Ahhhh...come on fucking guyRegistered User regular
    edited February 2010
    Holy fuckballs. The Health Insurance goose is right, sort of. This was really bothering me so I looked into it further and apparently HIPAA doesn't require an insurer to credit time on a group plan against pre-existing conditions to an individual plan if COBRA benefits haven't been exhausted. Unless Texas state law has a provision in place that strengthens HIPAA, they can actually make her stay on the employer sponsored group plan for 18 months.

    That is some serious fucking bullshit. I am sorry dude.



    Dept of Labor FAQ below.

    http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html
    How does HIPAA apply when changing from group health coverage to an individual insurance policy?
    HIPAA also protects those who are otherwise unable to get group health insurance.

    The law guarantees access to individual insurance policies and state high-risk pools for eligible individuals. They must meet all of the following criteria:

    Had coverage for at least 18 months, most recently in a group health plan, without a significant break;

    Lost group coverage but not because of fraud or nonpayment of premiums;

    Are not eligible for COBRA coverage; or if COBRA coverage was offered under Federal or state law, elected and exhausted it; and

    Are not eligible for coverage under another group health plan, Medicare, or Medicaid; or have any other health insurance coverage.

    The opportunity to buy an individual policy is the same whether a person quits a job, was fired, or was laid off.

    Deebaser on
  • bowenbowen How you doin'? Registered User regular
    edited February 2010
    1ddqd wrote: »
    Ok, so I went to work and couldn't check back, but here's what we're doing. Since her previous employer's coverage can be extended, even though it's more expensive, it's still a group policy, so we're cancelling the UnitedHealthcare individual policy and changing back to the original one. It's more expensive but she won't be considered a pre-existing condition.

    This whole thing has brought home to me just how fucked the industry is.

    I was for health care reform before, but now I'm absolutely behind it. Fucking rediculous. This whole thing had her in tears. She asked, with tears streaming down her face "I don't get it, if I want coverage and I'm willing to pay, why won't they cover me?"

    It was heartbreaking knowing what she was feeling (considering what she's been going through). I was literally | | <---that close to going down to the court and getting eloped so she'd have coverage through mine.

    Welcome to the club.

    Most Americans don't realize how fucked they are or will be until they get sick with more than the flu or a broken bone.

    bowen on
    not a doctor, not a lawyer, examples I use may not be fully researched so don't take out of context plz, don't @ me
  • 1ddqd1ddqd Registered User regular
    edited February 2010
    Yeah of those qualifications, she only misses out on the COBRA one about it not being exhausted; every other one is met.

    We cancelled the insurance and got our money back. We had her mom and grandmother chip in some money so we could get her back on the COBRA stuff so she'd be covered, then took her to the hospital to run tests.

    We're into the health business now - they've run their tests and according to them, she's entirely healthy! Well, that is, on paper. In real life, her sides hurt, she can't eat much, she can't sleep because she feels pain, and one of her lymph nodes on her neck is inflamed and kind of...protruding.

    We're a couple days away from getting one final test back. Barring the results of that (they've done everything from a CT scan to a complete blood and urine analysis) we're heading to a real life Dr. House (specialist of internal medicine or something). On a more depressing note, they found a cyst in her left ovary (but her pains are mainly on the right). She's headed to the OBGYN to get it checked out.

    Ok, now here's my question after that back story. She is a contractor-for-hire with Humana right now. She has been told that they're not to take any time off for sick leave or anything because they have "strict" time off requirements. She showed me this fucking self-righteous email about how one should wash their hands, clean their desk, and scrub themselves at home to keep from being sick.

    I realize this doesn't apply at all to my g/f as she has no common ailment. How legal is it for them to terminate her employment, even though she's called in every day she can't come in due to tests and medication? She's given appropriate notice and isn't taking sick pay (I don't believe it's even an option for her).

    1ddqd on
  • DeebaserDeebaser on my way to work in a suit and a tie Ahhhh...come on fucking guyRegistered User regular
    edited February 2010
    1ddqd wrote: »

    We're a couple days away from getting one final test back. Barring the results of that (they've done everything from a CT scan to a complete blood and urine analysis) we're heading to a real life Dr. House (specialist of internal medicine or something). On a more depressing note, they found a cyst in her left ovary (but her pains are mainly on the right). She's headed to the OBGYN to get it checked out.

    Whoa. Full stop. She hadn't been diagnosed with anything or had symptoms before the effective date of the individual plan? That isn't a pre-existing condition. I would fire off a complaint to the AG and DOI because that is complete horse shit and they're dicking with her because as an individual policy with a potential health issue it's cheaper for them to fuck around.
    1ddqd wrote: »
    Ok, now here's my question after that back story. She is a contractor-for-hire with Humana right now.

    This is just fucking awesome. She's working for a health insurance company that is paying her as a contractor to avoid providing a benefit that costs them practically nothing after they claim the tax write off for providing it.

    Fuck the DOI, write your senators pretty fucking please.

    Deebaser on
  • AvicusAvicus Registered User regular
    edited February 2010
    1ddqd wrote: »
    We're a couple days away from getting one final test back. Barring the results of that (they've done everything from a CT scan to a complete blood and urine analysis) we're heading to a real life Dr. House (specialist of internal medicine or something). On a more depressing note, they found a cyst in her left ovary (but her pains are mainly on the right). She's headed to the OBGYN to get it checked out.

    Don't worry yourself too much about the ovarian cyst at this stage. From what I have heard, they are fairly common. If it is just a small one, they will basically just leave it and it will go away eventually. If it is big they may have to surgically remove it.

    Avicus on
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  • chknsandwichchknsandwich Registered User regular
    edited February 2010
    Avicus wrote: »
    1ddqd wrote: »
    We're a couple days away from getting one final test back. Barring the results of that (they've done everything from a CT scan to a complete blood and urine analysis) we're heading to a real life Dr. House (specialist of internal medicine or something). On a more depressing note, they found a cyst in her left ovary (but her pains are mainly on the right). She's headed to the OBGYN to get it checked out.

    Don't worry yourself too much about the ovarian cyst at this stage. From what I have heard, they are fairly common. If it is just a small one, they will basically just leave it and it will go away eventually. If it is big they may have to surgically remove it.

    Are you a doctor? Have you examined his gf? Are you an expert in the field of cysts? Maybe you should let the doctors handle the medical advice :?

    chknsandwich on
  • bowenbowen How you doin'? Registered User regular
    edited February 2010
    Most ovarian cysts are benign, and are in fact pretty common, is what he was trying to say. To stem away from this "OMG CANCER" notion he may be getting because of "pre-existing condition" claim from the insurance.

    Edit:

    Wikipedia has this to say:
    An ovarian cyst is any collection of fluid, surrounded by a very thin wall, within an ovary. Any ovarian follicle that is larger than about two centimeters is termed an ovarian cyst. An ovarian cyst can be as small as a pea, or larger than an orange.

    Most ovarian cysts are functional in nature, and harmless (benign).[1] In the US, ovarian cysts are found in nearly all premenopausal women, and in up to 14.8% of postmenopausal women.

    Ovarian cysts affect women of all ages. They occur most often, however, during a woman's childbearing years.

    Some ovarian cysts cause problems, such as bleeding and pain. Surgery may be required to remove cysts larger than 5 centimeters in diameter.

    bowen on
    not a doctor, not a lawyer, examples I use may not be fully researched so don't take out of context plz, don't @ me
  • DruhimDruhim Registered User, ClubPA regular
    edited February 2010
    Avicus never said she shouldn't see a doctor, he just said it probably won't need any intervention. Calm down people.

    Druhim on
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  • bowenbowen How you doin'? Registered User regular
    edited February 2010
    ^ What the bear/otter said.

    bowen on
    not a doctor, not a lawyer, examples I use may not be fully researched so don't take out of context plz, don't @ me
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