Claims Denied in 2014 for Pre-Existing Condition? (Large Group Plan)
My brother became eligible June 1, 2013 to participate in his employer’s large group health insurance. Because he was not eligible prior to this date, he was a “late enrollee.”
He has hemophilia (blood clotting disorder). In early 2014, he obtained a prior authorization for varicose vein leg treatments. He already had a pre-certification for receiving Factor IX (specialized pharmaceutical to temporarily make his blood clot).
He had his first leg treatment in March and the second leg was done in April. Factor IX charges for each of these outpatient procedures was slightly over $50,000 – total of over $100,000. When the claims were processed, they were denied for a pre-existing condition.
We were stunned and questioned this decision by the insurance company. We were told that because he was a late enrollee, they could still use the 18-month look-back period allowed in Minnesota prior to the ACA provisions that went into effect January 1, 2014. Is this true?
How can they pretend that your benefits will cover your outpatient procedure and the specialized medicine you need, and then deny the benefits AFTER you have the procedure?
They knew he had hemophilia for years before these claims were submitted and denied (he received a dose of Factor IX in 2013 for an episode of bleeding when urinating). He was also a previous subscriber to the plan before he was laid off in 2007.
I think that when they saw the cost, they denied the claims.
I thought this kind of treatment by insurance companies was illegal under the ACA provisions that are currently in effect. Please help my brother and I understand why this is happening or what we can do about it.
All non-grandfathered plans sold after 2014, that count as comprehensive coverage, have to cover preexisting conditions without exclusions or look-back periods. The only loophole is that if you seek treatment during a time you aren't on a plan, that treatment isn't covered.
Before the ACA states could use look-back periods of up to 60 months to deny a claim, but not anymore. That being said, under the old rules Minnesota specifically had an 18 month look-back period.
The caveat here may be that it is a grandfathered plan, and thus is still using the old rules. However, a large group plan that is a grandfathered plan really shouldn't be being offered by an employer here in 2015.
You should begin the appeal process immediately. Please keep us updated so we can help.
Learn more about the history of preexisting conditions and how the PPACA protects everyone on new plans starting after 2014.
Learn more about your right to an appeal.