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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.


Insurance Changing With Surgery Scheduled

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Question: I have bariatric surgery scheduled for July 3rd under my Group Plan. Today I received notificaiton from my company this plan is being withdrawn and preplaced with 2 other options as of July 1st. I’ve had 6 months of workup prepration for this surgery and now I’m loosing the insurance. I’ve called my surgeon to see if we can move up the date. I have a few questions: even if I selected a new goup plan that my company is forcing me to pick from and different than what I have now, assuming this procedure will be coverd under a new plan, will I be forced to go through all the work up again for the new plan? Can I be denied for pre-existing condition - whether I have the surgury sooner and not be forced to the new plan or wait and have surgery under the new plan? What if I have complicaitons after the surgery on the new plan. Mindful, the new plan is not my choice, but my employer will drop what I have now and offer other plans. Please advise. (I live in CT, have a primary Dr. in CT, but my insurance company is out of Mass.)

Answer: The crux of your question is which insurance company is responsible for a claim when there is a change of insurers. In your case this change is taking place on July 1st, so the current insurance company is responsible for all medical services you receive prior to July 1st. These responsibilities are based on the dates-of-service not the date the claim is submitted or received by the insurer. The “new” insurance company would be responsible for your surgery assuming it’s done as scheduled on July 3rd. If you have the surgery done before July 1 you will need routine follow-up and if there are complications that require treatment, those claims will be the responsibility of the “new” company. No - you cannot be denied coverage for preexisting conditions under Massachusetts laws.

Your primary problem right now is that you don’t know if the new insurance plan will cover the bariatric surgery. You need to find that out right away. It either does or it does not. It’s not based on your circumstances. If the answer is “no”, you have to move up your surgery up. If the answer is “maybe”, I would still advise you get it done before July 1st.

Secondarily, you will have to find out if your surgeon is in the new insurance company’s provider network. If not and you have to switch surgeons, then it’s quite possible the new surgeon will require additional surgical workup and your surgery will have to be rescheduled.

2 Comments

I was a school bus driver my insurance is paid for 18 weeks so when we are off over the summer we are covered until September when we go back to work Our company lost there contract with the school district and we lost our jobs our insurance was already paid and should cover us over the summer I have breast cancer and was scheduled to have surgery on July 6th 2017 and have had all my pre test for this operation now I find out they are canceling us as of July 1st and want to re- emberse us the three months we already paid because of the company not having jobs for us are they liable to cover me

I just found out that I am in this same situation, but different surgical procedure. (I am in Missouri, if that is relevant.) I have surgery scheduled for June 3rd for a hysterectomy. I have 2 large masses of fibroids that cause a lot of pain, and am passed the age of having more children.
Today is May 22nd and I just received notice that my employer is switching insurance carriers, effective June 1st (2 days before my scheduled surgery). I am a week and a half away from the scheduled surgery, and everything has already been arranged for this time frame. Is there a possibility that the new insurance carrier will say they won’t cover it?

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