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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.

Grounds for Denial of Medical Claim

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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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