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retro denial question

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PMRNC:
No.. this is a different topic. There is a difference between RECISSION and Cancellation. Also the plan could have been an ERISA policy.. we don't know.
If you read this paragraph again, you will see that those above regs are there to protect those who's coverage is recinded due to errors on application for coverage (EOI)


--- Quote ---"post-claims underwriting" defined as rescinding, canceling, 
            or limiting of a plan contract due to a plan or insurer's 
            failure to complete medical underwriting and resolve all 
            reasonable questions arising from written information 
            submitted on or with an application before issuing the plan 
            contract or policy.  For health plans regulated by DMHC, 
            provides that the prohibition against post-claims underwriting 
            does not limit a plan's remedies upon a showing of willful 
            misrepresentation. 
--- End quote ---

In regards to coverage cancellation.. if it was a premium issue (cobra, etc) Underwriting applies the grace period..when the grace period is past, if claims were submitted they were paid..they have a right to go back and request payment refunds. It is IMPOSSIBLE for underwriting to determine a plan cancellation during the grace period unless the employer actually cancels, if they are just not sending in premium, Underwriting can only apply grace period and wait to see if the check is received. I worked for an insurance company and for the state of California, any examiner who process claims in the state of California has to be certified to process california claims so we had to know their laws specifically in order to process claims. This issue came up all the time due to the verbiage those regs were meant to protect those innocent application omissions or errors for EOI (Evidence of Insurability) they were not meant to be protective of non payment of premium. The issue for the patient in question should be with the employer (labor laws, etc) NOT the insurance company.

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