Pre-existing condition? help!!

Is a employee subject to the Pre-existing condition if he/she is enrolling at our company's open enrollment time?, What happens if the employee has never had any previous medical coverage?



  • 3 Comments sorted by Votes Date Added
  • It depends on what your policy says about pre-existing conditions first. Then there is a federal law. HIPPA says that if the employee can prove he/she had coverage under some other plan for the pre-existing period, your insurer cannot enforce the pre-existing. Pregnancy is an exception to any preexisting requirement. In reality, you really cannot make pregnancy a preexisting. You pretty much have to cover all pregnancies. Call your insurer to review your policy and have them explain how your policy is effected by HIPPA.

    Margaret Morford
  • [font size="1" color="#FF0000"]LAST EDITED ON 04-01-02 AT 09:00AM (CST)[/font][p][font size="1" color="#FF0000"]LAST EDITED ON 04-01-02 AT 07:51 AM (CST)[/font]

    Two questions here. First as to the relationship between pre-existing condition and open enrollment. Actually, there is no relationship. Either the pre-existing condition exists and therefore raises certain obligations and rights or it does not exist . If the pre-existing condtion exists you must enroll though you can delay the coverage for up to the full exclusion period 12 months, or up to 18 months if the new employee enrolls late, i.e. waits for the next enrollment cycle. If no pre-existing condition exists, there is no such condition to raise the matter of an exclusion period. Of course such exclusion is subject to the amount of creditable coverage available to the employee from previous coverage. You must check with the employee and your insurance company on this. Then you ask about what happens if the employee had no previous medical coverage. If this is the case and assuming the employee had a pre-existing condition, you can exclude for up to the maximum exclusion period (12 months or 18, as referenced above). However, be careful about what you mean by "no medical coverage". The types of coverage that provide credit against the exclusion period are varied. For example creditable coverage includes any group plan, health insurance, medicare, medicaid, or a public health plan. It does not include accedent coverage, disability insurance, liability insurance, liability supplements, worker's comp, auto insurance, or on-site medical coverage.
    Stanley P. Santire
    Executive Director
    The PEER Institute
    Houston, Texas
  • I strongly recommend checking with your provider. Some states (Washington for instance)have regs which are more restrictive then federal.
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