Can a group health insurance deny coverage based on pre existing condition if they have no written explanation of such limitations and conditions? I have diabetes and need medications and tests regularly. It’s a big deal if I’m not covered for this!
It’s in there somewhere or they wouldn’t be able to turn down your claim. The claim denial should tell you exactly the words from the certificate that is the basis for the denial.
A group plan cannot deny your bills for a pre-existing condition if you have had continuous coverage (or a lapse of less than 63 days). They may need a letter from your previous plan, called a “Creditable Coverage” letter. Call the plan and find out what they need. The phone number is on the back of your ID card.
If you are not satisfied with their answer, you can appeal the decision. The denial letter should also give you instructions about how to appeal the decision.
This will all be gone in 2014, when healthr reform requires all health plans to cover pre-existing conditions. Until then, you will have to deal with the plan’s rules.