This section provides basic information to help you make decisions about your insurance coverage for health, life, and disability. If you have any questions or concerns not addressed here, consult your insurance agent or an insurance counselor. Your local AIDS service organization or local PWA group may provide you with the assistance you need.
The information provided here is intended to address the individual who has been diagnosed with symptomatic HIV or AIDS. If you have not received such a diagnosis, there will be other options available. You may want to refer to more general literature on the subject of insurance, or consult an insurance specialist to answer your questions.
If you become employed after your diagnosis, depending on the size of your employer, you may be eligible for insurance plans that do not require medical screening. Be sure that you understand your eligibility for -- and other terms of -- any insurance plans offered by a new employer before you discontinue any of your existing insurance coverage. For individuals, Empire Blue Cross/Blue Shield offers an "open enrollment" health insurance policy that is available to everyone regardless of their medical status. You may even be able to use the open enrollment policy to improve upon your existing insurance coverage. However, open enrollment coverage requires you to pay a portion of your medical expenses, and you may have to wait eleven months to get covered if you are already diagnosed with AIDS (but see below). The open enrollment plan is for health insurance only. If you have already been diagnosed, the reality is that it is unlikely you will be able to obtain disability or life insurance, except perhaps through a large group plan that requires you to submit no medical information.
Under a federal law called Cobra, if you leave your job you are entitled to continue coverage under your group health insurance plan. You pay the cost of group coverage plus an administrative fee to your employer, and the employer keeps you on the plan. After employment is terminated, Cobra coverage lasts for eighteen months under most circumstances, 29 months if the Social Security Administration determines you were disabled when you stopped working (and you send your Notice of Award to your former employer within 60 days of receiving it), or 36 months if you lost your insurance because of a divorce or death of a family member. You must, however, promptly notify your employer if you wish to be covered under Cobra, and you will have to pay the premiums yourself (although, if you are eligible, Medicaid may pay them for you).
Under New York State law, you have the right to convert your health insurance to an individual plan so long as your employer is promptly notified. You also have the right to extend your group coverage for up to twelve months -- free of charge -- for a disabling condition if you are disabled at the time your coverage terminates. You could do this as soon as you leave your job, but usually it will be to your advantage to do it at the end of the Cobra period. The coverage you get under a private, individual plan will almost certainly not be as good as your group plan, and it will probably be more expensive. But your health insurance may be the most valuable thing you have, and it is extremely important to maintain it. Although the coverage provided under the twelve month extension is the same as that provided under the group plan, it only extends to claims related to your disabling condition (e.g., if your disabling condition is AIDS, AZT will be covered, but treatment for a broken leg will not be covered). If you need to convert your policy or extend your benefits, please consult an insurance specialist for advice.
Note that if your employer is self-insured (the employer sets aside company money for paying claims and hires an insurance company only to process the claims), your health insurance plan is not required to offer you a conversion policy or an extension of benefits.
Cobra does not apply to disability or life insurance. In New York, you have the option to convert your group life insurance to an individual policy on which you would have to pay the premiums, or you may be able to continue your group life insurance coverage at no cost if you are disabled when you leave your job. You will probably not be able to continue employer-sponsored disability insurance; you should read your policy to see if you have any conversion rights.
If you are in a group plan and have been so for a long period of time, there should be no problem with your insurance claim. If, however, you are with a new insurance company, the company may claim that you have a "pre-existing condition" and refuse to honor your claims for that condition for a certain period of time (but see below). Finally, if you work for an employer who is self-insured (as described above), the employer may be allowed under federal law to limit coverage for specific illnesses (see below).
Under New York law, insurance is a contract between you and the insurance company, and it cannot be canceled because you get AIDS or any other illness. The insurance company can, of course, cancel your policy if you are required to pay the premiums and don't do so. The company may also be able to rescind your policy if your insurance application contained a material misrepresentation about your health, as described below. Some policies must be renewed from time to time, and the insurance company may have the right not to renew the policy. Under the federal law that applies to group self-insured plans, your employer may be able to exclude AIDS-related care from coverage entirely or set a cap on the amount of benefits you can receive for AIDS-related conditions (for example, a self-insured plan may have a lifetime maximum of $1 million in benefits for every illness except AIDS for which there is a $25,000 maximum). If your health plan has such a cap or exclusion, you should contact an insurance specialist to evaluate your options.
Under New York law, you have a pre-existing condition if you sought medical treatment for a condition, or if you had symptoms of a condition before you took out the policy. Most policies have a pre-existing condition clause stating that, for a certain period of time, any such pre-existing condition will not be covered. A common time period for pre-existing conditions is twelve months, so any illness or condition you had when you took out the policy will not be covered during the first twelve months the policy is in effect. It is important to emphasize, however, that after the expiration of the pre-existing condition period the policy will cover you for that condition.
Further, the applicability of pre-existing condition periods has now been limited in an important way. If you were covered by another policy within 60 days before starting on your new policy, the new policy has to give you credit for the time you spent on the old policy. So, if you were on the old policy for twelve months and then went onto a new policy which has a twelve month pre-existing condition period, the new policy would have to give you credit for the time spent under the old policy and cover you for all pre-existing conditions immediately. Further, a recent change in the law, effective soon, provides that this crediting of time on an old policy against the pre-existing condition period of a new one also applies to disability policies. Under the federal law that applies to group self-insured plans, there is no standard definition of a pre-existing condition and no limit on the amount of time you can be excluded from coverage for such a condition.
Remember, the best way to handle problems with insurance is to avoid them by being informed. And the best time to learn about your coverage is before you buy it, or at least before you have to submit a claim. By fully understanding your benefits, you'll be in a much better position to negotiate problems if they arise.
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