Can Health Insurance Company Demands Preexisting Condition Forms After One Full Year

[victrelis]

My question involves insurance law for the state of: Florida.

Hi, my mother who is 58 years old has commercial health insurance coverage with Aetna. Four months after her coverage starts (she does not have health coverage before), she was diagnosed with Hepatitis B that requires her to have periodic blood work and doctor visits. Now the preexisting condition clause of Aetna involves a 6 month period- so everytime she did her blood work and scheduled visit her doctor has to fill out the form that states that it is not a preexisting condition (this is all for the same diagnosis code).

She just got her blood work done again, but this time it is already more than one year since her coverage starts with Aetna. They require the preexisting condition form again. I called and they told me they will require it every time. From what I understand wouldn't preexisting condition become inapplicable after one full year of insurance coverage, regardless of what the policy is (and it only states 6 months)? I mean if we have to do it, we will but it is a huge hassle.

Please help me shed some light on this matter. Thank you very much for your time!

[cbg]

Very, very important. Does she have this insurance through her employer or her spouse's employer, or is it individual insurance that she buys completely on her own?

[victrelis]

Hi, thank you for your reply. She buys the insurance on her own (individual). She did not have health insurance before.

[cbg]

The laws which limit the amount of time an insurance carrier can consider a condition pre-existing are not the same for individual as for group insurance. I'm not even sure if there ARE any laws limiting the time a condition can be considered pre-ex for an individual policy. You are correct that on a GROUP policy, the maximum time a condition can be considered pre-ex is one year after the policy went into effect. Not so for individual policies. If they want a form every year, then lacking a state law that says otherwise, you complete a form every year. You can ask the Florida Division of Insurance if they have any limits but that's about the only out I see for you.

[victrelis]

Hi, thank you for your reply. I will contact the state next week to find out. But just in case there is no state laws regarding this, and it falls back into the policy, does this language (in bold) mean that the preexisting condition clause is only applicable for 12 months (I copied and pasted from her policy) (by the way what is a late enrollee? it seems it does not apply to a late enrolle but I don't understand what it means)

Preexisting Conditions.
A preexisting condition is a physical or mental condition, regardless of the cause of the condition,
for which medical advise, diagnosis, care, or treatment was recommended or received within the 6
month period immediately prior to the date the Member first becomes covered by this Contract,
medical treatment, services, or supplies were received or prescription drugs or medicines were
taken prior to the Member’s Effective Date of Coverage under HMO. The time used to satisfy any
applicable waiting period will be credited to the preexisting condition limitation period. No
waiting period credit will apply to late enrollees.
The preexisting condition limitation does not apply to pregnancy or to a newborn, an adopted
child under age 18, or a child placed for adoption under age 18, if the child becomes covered
under Creditable Coverage within 31 days of birth, adoption, or placement for adoption. Genetic
information will not be treated as a preexisting condition in the absence of a diagnosis of the
condition related to that information.
The preexisting condition limitation does not apply to eligible individuals and any eligible
dependents enrolling for coverage under a special enrollment period.
With respect to timely enrollees, treatment received after the Member’s Effective Date of
Coverage; and before the end of the 12 month period after the earlier to occur of the Member’s
Effective Date of Coverage, or enrollment date; related to a preexisting condition that manifested
itself during the 6 month period immediately preceding the Member’s enrollment date, will not be
covered.
HMOFL INDV COC-1 COMP2 (06/09) 23
HMO waives this preexisting condition limitation provision if, under a prior group or individual
health benefits plan, there has been a significant break in coverage for not more than a 63
consecutive day period, except that neither a waiting period nor an affiliation period is taken into
account in determining a significant break in coverage. The preexisting condition limitation
period will be reduced by the number of days of prior Creditable Coverage the Member has as of
the Effective Date of Coverage under this Contract or the first day of a waiting period.

[cbg]

This is the language for a group policy. You cut and pasted this directly from HER specific individual policy? Or from the website of the insurance carrier, who may also sell group policies?

I'm not arguing with you, I'm asking.

[victrelis]

Hi, it is from her specific "contract" (AETNA HEALTH INC.(FLORIDA) INDIVIDUAL ADVANTAGE COVERAGE). But you are right- after reading through the rest of her document I feel it is very generic and just does not sound like it was written for her specific plan. Actually I have a copy of an email correspondent from Aetna customer service from last year (when we first have this issue), stating that after one full year the preexisting condition clause will not affect us anymore. The hard part about Aetna is everytime you call or email them you get a different person, and each one has their own story to tell. Well I guess I will just do what they want, and if they give me further troubles I may have to complain to the state with an attachment of the previous email. I will post back here with any updates. Thank you very much!