If you have questions about the practices of your managed-care coverage, ask the experts at the state Department of Managed Health Care. They take up issues ranging from difficulties getting an appointment to denial of a doctor's recommendation for treatment.
My 26-year-old son was covered by health insurance through his employer until he was laid off last November. He was in the middle of treatment for severe colitis.
Six months lapsed before he could afford coverage again. Now that health plan refuses to give him coverage due to a "pre-existing" condition and took three months to tell him he was denied.
Fortunately, his colitis is in remission, but this means he cannot even be seen for an ear infection. Can the health plan do this?
He is working again and has passed the three-month waiting period to sign up for insurance, but will he be denied everywhere now?
– Concerned Parent, Roseville
When an employer provides health coverage through a group plan, all its participating employees are covered, regardless of their health status.
Because it is a large pool of health plan members, some of whom use a lot of services and some of whom use a little, the health plan is able to cover all those employees for a lower price.
However, when an individual purchases insurance, he does not have the benefit of being part of a large pool where the risk averages out. The health plan then performs "medical underwriting" to determine whether that individual has any pre-existing conditions that could be expensive to treat.
If so, that person will either have to pay more for health care coverage or deal with denial of coverage.
In California, a health plan can deny individual coverage for someone due to a pre-existing condition, even to someone who was previously a member.
In your son's case, he can now enroll in group health coverage offered by his new employer, and because it is a group policy, the health plan cannot deny coverage based on a pre-existing condition.
However, there may be a certain waiting period before the health plan will begin to provide coverage for care related to that pre-existing condition, so he needs to discuss his options with his employer before deciding which health plan will best meet his needs.
If he decides to switch to a different health plan, he can request that his medical records be transferred.
To ask a question, go to www.sacbee.com/ask or write Second Opinion; Features Department; The Sacramento Bee, P.O. Box 15779, Sacramento, CA 95852.
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