First here is some background information…

I have been receiving methadone maintenance treatment for opiate addiction non stop for 6 years. when i first began receiving treatment i had insurance through my employer and they covered it.

In August 2013 I was let go due to company restructuring and lost my insurance. In November 2013 I found a new job and started receiving insurance in December of 2013 through my new employer.

My insurance plan covers substance abuse treatment.

I had insurance through my employer with Humana beginning Dec 2013 through Dec 31 2014.(Beginning Jan 2015 my employer changed insurance providers)

I go to a methadone clinic for opiate addiction. They do not accept insurance so I pay cash at a rate of $110 per week. I filed a claim with my insurance provider to receive reimbursement for the substance abuse treatment i received, and they denied my claim for treatment for the dates starting jan 2014 through October 2014 because they said it is a pre existing condition, and said that I had to wait 1 year before I could be covered for this.

They said because I had a gap in insurance coverage longer than 63 days when I lost my previous job that they would not cover it. I have been treated for this condition ongoing for 6 years never a gap in treatment.

My question is, I thought with the new laws that there were no more ore existing condition exclusions? Can they legally deny my claim because its a pre existing condition?

Thank you for your help. I hope I provided enough information


Insurers can still use loopholes to deny claims for preexisting conditions, although all new plans have to cover you, can't drop you for being sick, can't charge you more, and must pay claims on covered benefits.

The loophole you fell into is that you had a coverage gap, and your insurer used that as an excuse to not pay for your addiction services (even though they are an essential benefit). If something like this happens you need to appeal, and appeal, and appeal.

Learn more about preexisting conditions rules

Learn more about your right to an appeal

ps. This is why the whole preexisting conditions thing is so important. Insurers can and will use loopholes to avoid payment. The new GOP plans all take away the preexisting conditions clauses (creating even more loopholes just like this one). This creates an environment that does nothing but save corporations money, and make life harder for hardworking Americans trying to get help.

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Macy Shadson on

Are you aware that health insurance companies do not send out bill’s for renewal so that you have a coverage gap and therefore they will not pay for pre-existing conditions because of the loop-hole? These insurance companies and the loop-holes really need investigated…..please!
My insurance expired 1-day before I noticed it (at my Dr’s. office) so now they will not pay for my Thyroid testing because it is now falls into the ‘gap’.

Kenneth Williams on

I was in a car crash the other was giveing a ticket. The insurance co. Refuse payment because I was dienos with a problum .the doctors don’t know if it was my back or my hip. Now I get in this car crash and three days later I can’t walk and the resart of this crash i had to have my right hip repaced and from that the life had to be replaced. Please help