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Covered California Q&A

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.

April 2012 Archives

Question: I have been working for my company for 11 years I went on maternity leave and then my daughter had health problems and I developed post partum and couldn't return back to work, my company said no problem and continued to pay my full premium ever month I am now back to work and the health insurance company is fighting with my boss and wants to drop me from the plan are they allowed to?

Answer: I think I understand what happened and it's really bad luck for both you and your employer. The employer's health plan contract with the insurance company defines a specific length of time employees are to be covered while on maternity leave. Apparently you were out longer than the contracted time. Normally, this is something that would not come to light as long as your employer continued to pay your health insurance premium each month you were out. However, the insurance company will routinely re-certify a health plan and that includes a review of the most recent payroll tax records. If you did not appear on the payroll, you should not have been covered. The insurance company has the legal right not to pay your claim and rescind your coverage. It sucks, but it is what it is.

Question: Would like to quit my job because my mom is ill and need to take care of her. I have bone on bone with both knees and will need surgery down the road. I have been having steroid injections for the past 2 years and have been very helpful. My husband is planning on putting me on his plan what complications do you think we will have with getting me coverage?

Answer: If your husband’s health plan is a group health insurance plan. You will be able to be added to his plan on the month following your employment termination. Your loss of employer-sponsored group health insurance is a qualifying event that will enable your husband’s plan to pick you up without having to wait for his plan’s open enrollment period. If your husband’s health plan is individual health insurance, you will probably be declined. That will leave COBRA coverage as your next option.

Question: After applying for a medical plan and being accepted, then one month later having heart trouble - will policy pay?

Answer: If the insurance company can determine that your heart condition was pre-existing, they will not pay. They will look at your application with a microscope. For example this is the type of general question that should uncover a pre-existing condition.

  • “Within the last 5 years have you been advised by a healthcare provider to have, but have not yet had, surgery, treatment, examination, evaluation or test(s) for a medical condition?”

If the insurer can produce medical records or claims history that shows that you did not answer accurately, they will deny your medical claim and rescind your insurance - even if your oversight was not related to a heart condition.

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