Broker Check

Can my Group insurance deny coverage on a pre-existing condition?

| January 23, 2023

If you had a medical condition, whether it be mental or physical, prior to the year 2013, you knew what a pre-existing condition was. That’s because prior to 2013 and the Affordable Care Act, insurance carriers were able to deny claims for conditions, ailments, or surgeries if the insured had these problems before becoming insured.  

     In my opinion the Affordable Care Act hurt an already dysfunctional health system, but for all that I disagree with the Affordable Care Act, it made it so that insurance carriers could no longer deny claims because of pre-existing conditions. This was huge, especially for someone like me.  

     I was in a car accident when I was eighteen years old. I was thrown out the back seat of a car before the car landed on top of me. There wasn’t much of me that wasn’t injured. The biggest problem with the accident wasn’t just fighting for my life, it was also the fact that I didn’t have health insurance. So, once I finally made it out of the hospital, which wasn’t a guarantee, I wasn’t able to get health insurance that would cover my pre-existing conditions. Instead, it would only cover things that weren’t affected in the accident, which wasn’t much.   

     When you enroll in fully funded health insurance today that is ACA or Affordable Care Act compliant, you will not be asked any health questions and the carriers are no longer able to charge you an extra premium or deny your claims because of health. This, however, cannot be said about self-funded insurance. Self-funded insurance is not Affordable Act Compliant, but they can meet the minimum standards of what the government requires for minimum essential coverage and other penalties. 

     Many employers and employees are unaware that the rule for pre-existing changed, or they don’t understand what the rule means. One of the biggest miscommunications is from employees who already have coverage and their employer is changing plans weeks or days before a surgery, medical procedure, or childbirth. The employee usually thinks that the new insurance won’t cover the claims, but this is not the case. The new insurance company will most likely need to reapprove the procedure, but they can’t deny the claim because of pre-existing conditions.   

     If you don’t understand something with group health insurance, ask questions. If you feel like you’re talking to the wrong person, call Keaney Corporate Services. We know group insurance.