IQ expert Jason Beans: The lowdown on pre-existing health conditions

Jason Beans

Q: If you get treatment now for a condition, should you be worried about being denied coverage in the future because the insurance company knows about your health problem? What about denial by other insurers? Do they share information?

A: Your three questions deserve a three-part answer.

First, if you currently are insured and are being treated for a condition, you do not have to worry about being denied coverage in the future under your existing plan. However, if you switch plans and the new plan has a pre-existing condition clause, then it could limit your ability to get coverage for that specific condition.

As for your second question about the possibility of being denied by another insurer, that depends on two main factors:

1. Are you obtaining coverage through a company where you work or on your own as an individual?

2. Are you uninsured or have proof of previous coverage?

Your company’s health insurance plans may or may not have a pre-existing condition clause. This clause often can be waived if you can show proof of previous coverage.

If you do not have previous coverage, the company may require a pre-existing condition exclusion period lasting nine months. During this time, the insurance company will not cover treatment for the pre-existing condition.

The federal Health Insurance Portability and Accountability Act (HIPAA) ensures that your company cannot deny coverage based on a pre-existing condition. However, this is not the case for individual plans. If you are seeking insurance on your own, the landscape changes — obtaining coverage can be difficult if you have a pre-existing condition. If you are an adult trying to get insurance on your own, your application could be rejected or your pre-existing condition could be excluded from coverage.

The federal Patient Protection and Affordable Care Act will require health insurance companies to cover you regardless of a pre-existing condition. As of September 2010, children under age 19 no longer can be denied coverage because of a pre-existing condition. This same change kicks in for people 19 and older effective Jan. 1, 2014. Insurers will have to accept everyone who wants to purchase a plan, regardless of health status. This means health plans also won’t be able to exclude coverage of a pre-existing condition. However, that scenario could change depending on the outcome of a case pending before the U.S. Supreme Court.

As for your third point, you asked whether health insurance companies share information. Before your new insurance company pays your first claim, it will review your medical records to make sure your health history is consistent with the answers you provided to medical questions. If there’s no consistency there, the application will be considered fraudulent, your paid premiums will be returned and the claim will not be paid. That’s why being honest is so crucial.

In a previous column, I addressed the importance of being upfront on your health insurance application. However, you need only report what has been diagnosed and treated. You do not have to report every minor ache and pain.

Jason Beans is CEO of Chicago-based Rising Medical Solutions, a medical cost containment/care management company serving the workers’ compensation, group health, auto and liability markets. Beans founded Rising in 1999. Since then, Beans has received a number of honors, including Business Council Advisory Man of the Year and Midwest finalist for Ernst & Young Entrepreneur of the Year. Rising has appeared several times on the Private Company Index’s Top 10 Growth list and Inc. magazine’s Inc. 5000 list.

Beans earned a master’s degree from MIT’s Entrepreneurial Masters Program and a bachelor’s degree in finance from Boston College.

For more information, visit www.risingms.com.

If you have a health insurance question for Jason Beans, please send it to john.egan@insurancequotes.com.