Affordable Care: Hassles over pre-existing conditions will stop

“I have a pending claim with my insurance company. They’re delaying paying the receiver to do a “Claim and Eligibility Review”. What should I do? In a letter, they’d like to review my medical history from a few years ago, and would like me to authorize access. They place this caveat: “under no obligation to sign this form and that we may not condition payment health plan enrollment or benefits eligibility on my decision to sign this authorization, unless this authorization is being sought for determinations of health plan enrollment, eligibility, underwriting, or risk rating.”


 Dear Confused,

It sounds like they are trying to determine whether you had a pre-existing condition. Maybe you had a 63-or-more-day lapse in coverage before you joined this plan and this plan has pre-existing condition exclusion for the first 12 months. If one of those facts is not true (you had no lapse, or you have been on this plan for more than 12 months), then you should call the plan and contest their eligibility review. You may need a “letter of creditable coverage” from your previous plan to prove you did not have a lapse in coverage; they should have sent you this when your coverage ended with them. If not, they will give you another one.

Otherwise, if you want the claim paid, you will have to sign the authorization.

Take heart – this kind of thing will stop happening in a few months.  All plans will have to pay claims for your illness, no matter when your illness started or when you last had health coverage.  It’s part of the Affordable Care Act.

Linda Riddell

About Linda Riddell

A published author and health policy analyst with 25 years’ experience, Linda Riddell's goal is to alleviate the widespread ailment of not knowing what your health plan can do for you.