My coverage with Aetna ended on 5/31/08, coverage for CIGNA began on 6/18/08. We opted not to go with COBRA, after long discussions with them, because they said if anything happened, we could begin coverage with them, and avoid the $1300 payment. Since, it was for 18 days. My husband changed jobs, is the reason we had to change. No, I haven't given CIGNA any letter. But, I do have a "Certificate of Prior Coverage", from Aetna. I appreciate your input, I'm trying to get all the "info", before I call them and set off any alarms. I called my doctor's office, for their help. When they called to verify coverage before my check up, they verified it, and did not mention a "preexisting clause". Do you think those dates are crutial?

You officially joined the ranks of the "uninsured" between 06/01/08 and 06/17/08, that is a gap in healthcare coverage. This is why CIGNA is considering your medical condition as "pre-existing".

The National Association of Insurance Commissioners (NAIC) provides the following definition:

"A pre-existing condition is a physical or mental condition for which medical advice, a diagnosis, or care or treatment is recommended or received within a certain period of time before the enrollment date of the policy. Even if an insurance company approves your coverage, it might restrict coverage of pre-existing conditions completely or for a specified period of time."

You indicate in the post above: "We opted not to go with COBRA, after long discussions with them, because they said if anything happened, we could begin coverage with them, and avoid the $1300 payment." Are you referring to CIGNA when you talk about "them" and "they"? If yes, was the understanding of these long discussions that CIGNA would allow you to bridge the 18-day coverage gap? Is this why you decided not to elect COBRA coverage? Did CIGNA quote you a premium amount to cover your husband retroactively to 06/01/08? Was the amount quoted lower than what COBRA would have cost? Did you document these long discussions (dates, times, names)? It worries me that something that may have been said or promised by CIGNA persuaded you not to purchase COBRA within the mandated 60-day election period and now they would go back on their word.

It is not unheard of (but usually it is solely at the discretion of the insurance company) that the new insurer may allow you to "purchase" an individual policy that only covers the days you were left uninsured while between jobs (from 06/01/08 to 06/17/08). Even if they refute that they offered this gap coverage to you back in June, CIGNA may still be agreeable to entertain this now and I believe you have two things on your side:

1) the coverage gap is relatively small, less than two weeks and,
2) you are not currently ill with this pre-existing condition.

I think the question here is, if CIGNA agrees to close the 18-day gap with the purchase of the individual policy, will that effectively eliminate from their "books" your "pre-existing" condition and allow you to enjoy coverage without restrictions? I think it is crucial to have this addressed by CIGNA --in writing! You need to be reassured of exactly how bridging this gap will affect your and your husband's coverage in the future.

It may take a lot of calls and letters, but this may be worth pursuing. I would suggest the following:

- First of all, gather any documentation you received from CIGNA or your husband's employer (like a benefits or healthcare certificate booklet) when he enrolled in their health plan. Find out the clause that covers "pre-existing" conditions and be aware of what CIGNA would and would not cover. Some insurers may consider a condition "pre-existing" only during the first year of coverage, others may attach a Dollar amount to the coverage (for example, they may only cover $1000 worth of care related to the pre-existing condition), many have done away with the "pre-existing" clause altogether! The document probably has language relating to COBRA and proof of prior coverage.

- Make sure you have all documentation related to your prior coverage and your current coverage on hand.

- If you haven't done so already, make sure you keep a log of any calls you have made (dates, times, names of those you spoke to and a summary of what was discussed). If you haven't documented calls, you can still write down as much as you remember, but do it as soon as possible! E-mail is a great thing, if you can, send a follow-up e-mail to whomever you spoke with and re-state what was discussed over the phone.

- You may need to get a letter from your current doctor detailing your current status regarding your pre-existing condition and possible medical care you may need as follow-up in the next 3 to 5 years. The insurer may be swayed to come to an agreement if your prognosis is very good, you have been given a clean bill of health and future follow-up for the pre-existing condition is routine.

- Enlist the help of your husband's employer Human Resources department. Employers carry a lot of weight with insurance companies since they can take their business elsewhere. Just make sure you have all your documentation together, you want them to be your advocate and mediator. They will appreciate all the legwork you can do before contacting them.

If all of this fails, I would escalate the issue to the Georgia Department of Insurance. Put your hard-earned tax Dollars to work!

Dept of Insurance and Safety Fire Commissioner
Two Martin Luther King, Jr. Drive
West Tower, Suite 704
Atlanta, Georgia 30334
Main Telephone: 404-656-2070

Life and Health Division
404-656-2085
Life@oci.ga.gov

Good luck on your pursuit and I best wishes in your journey to good health!

Some final thoughts:

I would also see if the HR dept. would escalate the issue with the brokerage involved with the account. They tend to have "pull" and might be able to assist with getting the exception approved. Also, have them go over the SPD in great detail with your husband - you will want to know the precise provisions stated in the policy.

Finally, as stated above - Document, Document, Document!

Just trying to spread the knowledge. Few people get to know and understand all the "ins-and-outs" of health (or for that matter, any type of) insurance and the results can be devastating. I've worked in the industry for 19 years (Oh no, dating myself!) and still have a hard time following up on constant changes, new products, loopholes, mandates, you name it. Many subscribers who have been wronged just give up because they feel they have no chance to battle a Goliath. But I have seen persistent subscribers fight and bring the giants down to their knees. I feel Snoopy should fight and be made whole in this situation, it is the right thing to do.

I've been in the insurance biz (not med, but ancillary), for almost 6 years. It really is amazing to see what a little bit of general knowledge can do for your average member or policyholder.

I've had some family members encounter similar situations, and they are quite troubling....I'll never forget when someone close to me was diagnosed with an illness that was considered "outside the box". Their spouse was advised that certain treatments were considered experimental - I told the spouse to contact the DOI - and to advise of the company's practice. It really is amazing what a simple call can do - Or, an idle threat to someone in mgmt. can accomplish.

To anyone reading this, the best action is to become an educated consumer -- read up on your policies, shop them every year (In particular if you're an individual policyholder)! Every insured person should keep in mind that they are the consumer!!

Wow! Thanks for your detailed comments. I never contacted CIGNA. "Them", was referring to Cobra. In all of my papers, and discussions with Cobra, no one EVER mentioned that this would or might cause a problem...otherwise, it's a no brainer, we'd pay whatever the amount was. We never thought about calling CIGNA. Since my blog, yesterday, heres what I know. I went over all of my info for Cobra, nothing..nada..about "gap in coverage"..would lead to pre-existing condtion. I found a "Certificate of Prior Coverage", from Aetna, for 01/01/08-05/31/08. I started thinking, maybe I need this from Mutual of Omaha. I called them, they were extremely helpful..as they were amaizing during all of my treatment..they said they will send my certificate, dating 05/05/06-12/31/07, and that since there is only a 18 day gap, that should be fine. Typically, (as you may know), if there is a 60 day gap in coverage, either broken up or all together, it becomes a pre-ex condition. So, I called CIGNA, feeling confident. And, sure enough, I got a nice person, she said, that's all they needed and it should be sufficient information. I also contacted HR, with my husbands company. She will also follow up with her CIGNA rep. After reading their letter, again, it says: “We have received a claim for the services shown above. Your CIGNA HeathCare benefit plan has a pre-existing condition provision. To process your claim quickly and accurately, we need additional information. Please note: Expenses for Pre-Existing conditions are not covered, except as outlined in your plan, adjusted for any prior creditable coverage information you provided. You can send additional creditable coverage information to us. Once we receive this information, we will continue our review of the claim.” I realized that it just paniced me. If they would've just said, "We need proof of coverage for your past illness, with your previous insurance company's name and dates of coverage. Also, we need a "Certificate of Prior Coverage"...I would've understood that....Blame it on the chemo! I swear, I have a few less brain cells. I am confident that CIGNA won't fight me on the 18 days. But, if they do, yes, I have made some contacts and will pursue it..even I email Good Morning America! Oh! I also thought about going back and sending in the money for those 18 days. HR said we would need to take that up with his former employer. We can't do it now, we are over the 60 days. He left on an extremely high note. I swear, I wish I would've had some piece of info, in all my paperwork, about how important it is to have no gap incoverage. Thank you, again.

I am so glad to hear your problem may soon be resolved! It's good to hear that all of those you contacted were helpful and responsive. That's the way it should be!

I know my company is focusing on "transparency" (yep, I guess that is one of the buzzwords of the moment --it's just their fancy way of saying "no surprises") and moving towards "plain English" communication with our subscribers. This is a very welcomed change when you consider that many subscribers are probably dealing with very serious health issues at the time and may not have the werewithal to navigate the "legalese" and insurance jargon often found in benefit booklets/certificates, explanation of benefits and other forms of communication.

I wholeheartedly second Rock's statement that we need to become educated consumers and, hopefully, our posts in your blog will help spread the word. Again, my best wishes to you for a long and healthy life!!!