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Pregnancy as a preexisting condition in MA Massachusetts

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  • Pregnancy as a preexisting condition in MA Massachusetts

    To whom it is concerned,
    I live in Massachusetts and am having a problem with my short term disability insurance. I switched companies in June 7th, 2005. I signed up for my Health insurance, and Short Term Disability at this time and it was to commence on Sept 1, 2005. I called my doctor on 8/31/05 stating that I may be pregnant and they set me up for my first appt on 9/12/05 (first date of treatment). My health insurance picked up my care for the entire pregnancy but now that I am out on my FMLA leave, the STD company is saying I knew I was pregnant before the effective 9/1 date and it is therefore considered a preexisting condition. Can they say this if I did' t know I was pregnant and received no care prior to the effective date based on a phone conversation? I am desperate because I was not pregnant when I signed up for the insurance and I was found during my Sept 12th appt to be 7 weeks pregnant. Please help.
    Sincerely,
    Lisa Walker

  • #2
    Under Federal law, health insurance carriers are prohibited from considering pregnancy a pre-existing condition on employer sponsored group health plans.

    That law, however, does not apply to disability policies.

    The question is not whether you were pregnant when you signed up for the policy or even whether you knew about it; the question is whether you WERE pregnant when the policy commenced on September 1. Generally, however, a carrier does not apply a pre-ex clause unless you had already received treatment for the condition at the time the policy commenced. That's a policy thing, though, not a law thing.

    What does the STD policy booklet say about pre-existing conditions?
    The above answer, whatever it is, assumes that no legally binding and enforceable contract or CBA says otherwise. If it does, then the terms of the contract or CBA apply.

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    • #3
      Pregnancy as a preexisting condition in MA for STD

      This is the reason the claim was denied due to the
      pre-existing condition exclusion in the book they provided, "benefit amounts selected at initial enrollment, as well as increases selected during subsequent open enrollment periods, will be subject to pre-existing condition.
      Pre-existing condition means a sickness, injury, disability for which
      you received treatment within 12 months prior to your effective date. The Policy will not cover any Total Disability which is caused or contributed to by, or results from a Pre-existing condition; and which begins in the first 12 months after your effective date. "Treatment" means consultation, care or services provided by a Physician including diagnostic measures and taking prescibed drugs and medicines".

      Your effective date of coverage was 9/1/05. However, according to your
      doctor, you saw the doctor for your pregnancy prior to 9/1/05.
      Therefore, it was considered pre-existing and the claim was denied.

      However, just an FYI that my doctor wrote the wrong dates for the initial claim that I was seen on 8/12 instead of 9/12 (their mistake which they just submitted the revisions to the STD company and I am pending a response)...My concern is that while I received no treatment, what if they say that my calling to make the appt (ie "consultation") was admittance on my behalf that I was pregnant prior to the effective date. Can they continue to deny the claim based on this?

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      • #4
        Then you need to have your doctor write to them, explaining that he put the wrong dates and give them the correct dates. As far as the information they have now goes, you don't qualify for coverage based on the contract. How are they supposedc to know differently if no one tells them?*

        *In rereading your post I see that this has already been done. Stop worrying until you get their answer.

        A phone call setting up an appointment is not treatment. They cannot deny the claim based on the fact that you made the appointment before September 1.
        The above answer, whatever it is, assumes that no legally binding and enforceable contract or CBA says otherwise. If it does, then the terms of the contract or CBA apply.

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        • #5
          That last sentence is what I needed to hear...thank you so much...I didn't know if that is considered "consultation"-word games that insurance companies play!

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          • #6
            I have another question...the insurance company called back regarding a "family medical history" form that was filled out on 8/2 but this was not submitted until the first appointment on 9/12. It was mailed to me. Can they use this to say that I was pregnant back in August (I was interviewing doctors at the time since we wanted to get pregnant and dated it when I got the form even though I wasn't seen at that time). This person is trying hard to prove that this pregnancy was preexisting and requested my medical documents from 2004 from all of my doctors!!!

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            • #7
              Without having seen the document, I can't tell you for certain. But what does a family medical history have to do with whether you were or were not pregnant on any given date?
              The above answer, whatever it is, assumes that no legally binding and enforceable contract or CBA says otherwise. If it does, then the terms of the contract or CBA apply.

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