Can My Sister-in-law Be Denied for Maternity on a Group Plan?

[popeye35]

Thanks for the link. So if someone get's knocked up, they could simply get a job at Starbucks and all the maternity costs are covered from day one.

Good to see that the govt believes insurance covers unforseen expenses.

Rick

good point rick. I wonder if that would work on my car insurance. I could try to carry only liability until I get in an accident.

the sad thing is that I have had customers of mine (I do p&c also) call and try to add towing or rental car coverage after they have already been in an accident.

My sister-in-law's situation is kinda a tough situation for her. I think she should call the insurance company, and then if they tell her that she is not covered, she needs to do cobra instead (even though it is insane expensive).

 

[Josh]

Slightly off topic, but how do they know she's one month pregnant? They're 100% sure she's not just late?

Re: the health insurance portion of this, I believe she could just continue the cobra up until 60 days before the new coverage starts and it wouldn't even count as a pre-ex if it was one. I still don't think pregnancy is a pre-ex though, I agree that calling the carrier would be the best thing to do.

 

[DS4]

I agree that calling the carrier would be the best thing to do.

I don't know about your particular state but if you called customer service at any carrier here in Cali, your answer to a particular question would be all over the map. Are you really going to take the advise of someone that was serving slurpees 30 days ago at 7-11?
You almost have to apply a credibility factor to all answers you receive from carriers.
Example: Yesterday, one of my Anthem Med supp was moving to Oregon and wanted to know how this move effects her premium. Anthem divides Cali into 3 rate paying areas. In the past, if you moved out of Cali, your premium rate then moves to the highest rate paying area. I called Anthem to confirm if this was still the case. The first answer I got was "the premium remains the same', called again same answer for second, called again, same answer for third. Finally, on the fourth call, I spoke to someone with intelligence in the voice. "yes, highest premium rate area applies".
I guess what I'm saying, if you are giving advise to someone, you better be damn sure your advise is sound. Otherwise, don't give advise. If you have a question, do some research. Google is your friend. Figure out the answer to your own questions and then call the carrier to conform
I have made it 32 years in this industry and I've never been sued, or, seen the inside of a court room.


HIPAA, with respect to employer group plans,

Are there illnesses or injuries that cannot be subject to a preexisting condition exclusion?
Yes, as follows:

• Pregnancy, even if the woman had no prior coverage before enrolling in her current employer's plan.

 

[djs]

Are her health benefits provided by the union or by the school district? In my area, it's done through the union, so I'd be amazed there would be a change if her union membership doesn't lapse.

Dan
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I don't know about your particular state but if you called customer service at any carrier here in Cali, your answer to a particular question would be all over the map. Are you really going to take the advise of someone that was serving slurpees 30 days ago at 7-11?
You almost have to apply a credibility factor to all answers you receive from carriers.

Yes, but....
When I make these calls where I figure the answer could vary by the day and person answering, I simply record the conversation.

During the conversation, I also make sure I ask the question several times in different ways. I don't want the wrong answer, but I want a defensible answer for later. I also make sure I know who I'm talking to, note when, etc. If they can give me a reference number to the conversation, I take that as well.

I don't know of a carrier who doesn't add the line 'this call may be recorded for quality and training purposes' to their phone system while you are on hold. I just agree with them and start my recording, they are already aware the call is being recorded.

Dan

 

[Post Quartermaster]

As mentioned above, HIPPA doesn't allow pre-x exclusions for pregnancies...end of story.....

As far as "telling the carrier" or the carrier "finding out", keep in mind that she most likely won't be filling out a medical app, as she is treated as a new hire.....it's a group, don't worry about it.....happens all the time.....

 

[popeye35]

Slightly off topic, but how do they know she's one month pregnant? They're 100% sure she's not just late?

Re: the health insurance portion of this, I believe she could just continue the cobra up until 60 days before the new coverage starts and it wouldn't even count as a pre-ex if it was one. I still don't think pregnancy is a pre-ex though, I agree that calling the carrier would be the best thing to do.

I didn't mean literally exactly 1 month. It is more like 6 or 7 weeks at this point, so not quite 2 months. I'm pretty sure that pregnancy tests can detect it as soon as you miss a period.
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As mentioned above, HIPPA doesn't allow pre-x exclusions for pregnancies...end of story.....

As far as "telling the carrier" or the carrier "finding out", keep in mind that she most likely won't be filling out a medical app, as she is treated as a new hire.....it's a group, don't worry about it.....happens all the time.....

that sounds good. I was thinking the same thing. I mean, if you lose 1 job, and then get another, and you were pregnant at the time, it makes no sense that you would just be screwed out of maternity coverage.

 

[Post Quartermaster]

I didn't mean literally exactly 1 month. It is more like 6 or 7 weeks at this point, so not quite 2 months. I'm pretty sure that pregnancy tests can detect it as soon as you miss a period.
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that sounds good. I was thinking the same thing. I mean, if you lose 1 job, and then get another, and you were pregnant at the time, it makes no sense that you would just be screwed out of maternity coverage.

Even better, imagine a late 30's early 40's healthy, savvy business owner with a small company who employs him/her self as the GM....the rest of the group is a little sick, so the group premium is for the owners family is double what a $5K HSA IFP premium is....owner limits his hours on the clock to 29/ once per week every month(30hrs is f/t here).....wife gets pregnant, owner starts working 30+hrs every week, after 90 days qualifies as f/t employee on the group.......maternity is covered.....


Is it right? I'll let you decide. But, it's perfectly legal as long as it's done honestly and documented......



If I've seen it once.......

 

[LGilmore]

Here's a novel idea that rarely done.... check the plan booklet and read what the plan provision is for this situation.

You know what the plan booklet is right? It's that booklet that is never opened, read or consulted by an employee.
Plan booklets always look brand new at year end.

The plan booklet is part of the legal document and it will have the specifics, ya just have to look.

 

[ABC]

What blows me away is this thread was started by a agent.

You have a family member that has questions about coverage.

You come to a forum to ask if she is going to be covered.

This is beyond absurd.

 

[popeye35]

What blows me away is this thread was started by a agent.

You have a family member that has questions about coverage.

You come to a forum to ask if she is going to be covered.

This is beyond absurd.

If you had opened your eyes and fully read the first post, I DO NOT SELL GROUP HEALTH. I do not know how it works or the ends and outs of it. Furthermore, I mostly do p&c and life. I sell maybe 1 health policy per month. So I will readliy admit that I do not know anything about group health coverage.

I personally would not be so rude if someone who only sells life and health went over to the p&c forum and asked a legit question.