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Covered California and Obamacare related questions from consumers, employers and agents are answered by Phil Daigle with the best information available at the time. Archived entries may no longer be accurate as the Covered California and Obamacare knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.

Declined Coverage with Golden Rule

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Question: I recently applied and was declined for a condition that I have had for over 10 years and that no underlying cause has been found. When the condition does occur, which could happen once or twice in a year or not at all, the prescription used is of minimal cost. Should I appeal the decline?
Thank you.

Answer: Thanks for your question. Can you give me more information about the symptoms and treatment? Also, it sounds like you do not have a definitive diagnosis. Is that accurate?

In the absence of this information I can give you some general advice. It is sometimes worth making an appeal if you have new or different information than was originally provided on your application otherwise it can be a lengthy and fruitless process. Have you consulted your broker on the possibility of submitting an appeal or did your submit your application direct to Golden Rule Insurance Company? Part of the broker's job is to help the client provide information on or with their application that allows the underwriter to make a good decision. The space available on most applications does not allow for much of an explanation of a given health condition so a supplementary letter is often helpful. The underwriter's job is, as you correctly state, to review the cost of medications. They also need to know the diagnosis so that they can accurately assess the overall risk of the condition. It may be that, without a diagnosis, they are unable to get a good picture of the risk involved and had no alternative but to decline your application.

Get back to me on my questions if you can and I'll try and guide you further.

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