Preexisting Conditions

[Linda]

I am seeing post-HIPAA group health insurance policies and plans with the exclusions like -- no coverage for cosmetic surgery unless it is to correct an injury which took place while the person was covered by the plan. I see this as a permanent preexisting condition limitation. How do insurers justify this form of exclusion post-HIPAA? Or is this a pre-HIPAA provision that some insurers and TPAs have inadvertently carried over?

[Guest BENEFISH]

I don't see insurance policies excluding cosmetic surgery solely because it is pre-existing. I do see them excluding cosmetic surgery entirely. This is no different than any other exclusion under an insurance policy. HIPAA, to my knowledge, does not require that all expenses be covered carte blanche. Even the IRS does not allow exclusion from income under Section 213 for cosmetic surgery unless it is needed to improve congenital abnormality, personal injury, or disfiguring disease. I have never seen an insurance company knowingly pay for something that has to be included in the employee's income, HIPAA or no HIPAA.

[Linda]

It is not an issue of restricting cosmetic surgery to the correction of an injury (or a conjenital abnormality). It is a question of limiting the benefit based on whether the person was COVERED AT THE TIME OF THE INJURY (or at birth).

[Guest JDH]

Back up there, Benefish. I think you have misunderstood Linda's question. I agree with Linda that if the cosmetic surgery is excludable under 213 due to personal injury, then the question becomes how can the insurer exclude coverage just because the injury occurred prior to the covered person's coverage under the covered plan. It does sound like the exclusion occurs within the realm of pre-existing condition definitions. The insurance companies may be trying to get around this by saying the "injury" occurred prior to the effective date of coverage rather than saying the "pre-existing condition" existed. I don't believe such an exclusion would withstand the test of litigation.

[Guest BENEFISH]

I see your point JDH. Sorry for the confusion Linda. It's a Friday afternoon and I am thinking more "fish" than "bene".