Golden Rule 6 month wait on reproductive disorders?

Discussion in 'Health Insurance and Ancillary Benefits' started by newmindfashion, Sep 19, 2006.

  1. newmindfashion
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    newmindfashion Guru

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    Was wondering if anyone has some input on this limitation. Of all the limitations in Golden Rule policies, this one stands out: 6 month wait on reproductive disorders.

    What if someone developed a new cancer in that area within the first 6 months. Would that actually be declined? I'm waiting for them to call me back to clarify what services would and wouldn't be declined under this 6 month wait. I'm very concerned about this. Was wondering if any of you have inquired internally on this or have any point of view on this from prior experience.

    :?
     
  2. somarco
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    somarco That Medicare Guy

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    I am going to plead ignorance here. Is this something standard in policies issued in your state or is this a specific rider for a certain individual?
     
  3. newmindfashion
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    Somarco,
    This is listed as a general limitation on page 13 of the Golden Rule Health Plans Brochure for Florida, Page 13 for Connecticut and page 12 for Maryland. The Maryland brochure seems to be a standard brochure for most states.

    This is a pretty serious limitation. I like this carrier alot but I'm very concerned at the moment. It says that:

    "This provision will not apply if treatment is provided on an 'emergency' basis. 'Emergency' means a medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing a person's life or limb in danger if medical attention is not provided within 24 hours."

    Now, as everyone knows, ovarian or testicular cancers don't necessarily work that way where it all comes down to 24 hours. I'm waiting on the carrier to clarify. This exists in all plan brochures and prior creditable coverage does not eliminate this 6 month wait on treatment of tonsils, adenoids, hernia or ANY DISORDERS OF THE REPRODUCTIVE ORGANS acording to the company.

    Everyone's thoughts on this are appreciated. I need some assurances from the carrier on this.
     
  4. somarco
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    somarco That Medicare Guy

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    What we may or may not think about the provision really doesn't matter. In the end the carrier, and the contract, is the determining factor in adjudicating and paying (or denying) a claim.

    I don't see that provision in a GA brochure and review the limitations & exclusions of a real policy . . . dont see it there either.

    GR pulled out of GA last year, revamped their policy language, and returned. Could be it was in older versions and had to be dropped. Could be there now & I am missing it.

    I would think if it was anywhere it would be in the limitations & exclusions.

    I pulled the GA brochure and did a word search. Nothing turned up on "reproductive" and the only hits I got on "organ" pertained to organ transplant.

    Can you upload a copy of the document(s) for the rest of us to see?
     
  5. newmindfashion
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    newmindfashion Guru

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    Somarco,
    I sent you an email on this.
     
  6. BKrocko
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    That seems to be a standard policy provision in CO. There is a 6 mo waiting period but it is reduced by any period of time the covered person was covered under qualifying creditable coverage.

    Put yourself in the carriers position - they do not want to cover people who didn't think health insurance was important until they thought they had something. I don't really see anything wrong with it - I wish it were not there but it is fair.
     
  7. newmindfashion
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    I received communication on Golden Rule on this matter. Here's the deal:

    The language in their policy DOES allow them to deny a reproductive cancer w/in the first 6 months and prior coverage does not go against this wait (may be different for you in CO, BKrocko).

    However, they explained to me that although the policy DOES allow them to deny a claim on reproductive cancer in the first 6 months, they have paid all such claims that were new cancers w/in the first 6 months. Mainly because its the right thing to do.

    I have confidence that they will pay these claims because this clause was not drafted for the purpose of denying cancer but to prevent against abuse of the system in areas like hernias or other non-threatening conditions where a customer just wants to get insured, get fixed and then drop the coverage.

    Keep in mind though, the language allows them to do deny this type of claim. We have to hope they don't and will continue to do the right thing.
     
  8. somarco
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    somarco That Medicare Guy

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    Jesse -

    You sent me the wording in the response from GR and while I agree that it would be bad PR to deny cancer claims, the clause allows them to do so when the cancer EXISTED prior to the effective date of coverage.

    This gives them way too much wiggle room in my book.

    That clause is not in the GA plans.
     
  9. newmindfashion
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    Bob,
    The question I have then is this:

    If a person has no knowledge of or symptoms of cancer prior to applying and there's no medical records showing anything indicative of cancer, how would they OR ANY individual carrier be able to get around covering it? That's why major medical coverage is there.

    I do trust that Golden Rule has done and will continue do the right thing in these under 6 month cases. The 6 month wait on reproductive organ (and other stated conditions) was designed to prevent abuse, not to exclude cancer in that area of the body. The problem is the wording on "Emergency" exceptions where life or limb would be in reasonable jeopardy if not treated within 24 hours. Clearly cancer doesn't work that way. I would obviously prefer that they redefine the "Emergency" exception to the 6 month wait to include any newly manifested cancer.
    This is the kind of thing that media and/or captive competitors would go crazy with if they'd ever denied these in the past or ever started to deny legitimate new cancers of the reproductive organs.

    At this point I still have confidence in them but will need to discuss this limitation more closely with clients due to this potential loophole.
     
  10. somarco
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    somarco That Medicare Guy

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    As we discussed, cancer can be growing long before there are symptoms. By the time a lump shows up in a breast or testicle the cancer has been growing for some time. Seems to me the prudent man rule that has been the standard for so long would be a more reasonable approach.
     
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