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Switching from COBRA to individual coverage

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Last Modified: November 1, 2001

Dear OncoLink "Ask the Experts,"
My mother was diagnosed with stage II breast cancer in January 1996 and underwent lumpectomy, chemotherapy and radiation therapy. During the process, she was covered by the HMO plan provided by my father's employer. However, my father just recently took a job overseas and my mother decided to stay in the U.S.(she has completed all treatments). She's currently covered by COBRA and wishes to change to an individual plan with the same HMO.

Last week, the insurance company denied her appication for individual coverage "due to her medical history". In the letter we received, the HMO company did not provide specific reasons for the denial, but said they would release the information to the doctor of our choice if we request so in writing.

It is to my understanding that insurance companies are prohibited to exclude people with pre-existing conditions by the Kassebaum-Kennedy Health Insurance Bill.

1. Did my mother's insurance company violate the law by rejecting her?
2. What steps should we take if we wish to fight the insurance company's decision?
3. Do you have any advice on how to obtain health insurance if we are not able to continue her current HMO coverage after the COBRA plan expires?

We suggest that the reader review the response to a previous OncoLink question related to pre-existing condition coverage: "Dealing With Outstanding Medical Bills and Coverage for Screening Procedures, and Pre-Existing Conditions." In addition, we strongly urge the patient to follow through with the HMO's procedures to obtain the specific reasons for their denial. Compare the HMO's denial rationale against the terms of the Kennedy - Kassebaum Bill (see also THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 ("KASSEBAUM-KENNEDY") .

If your mother meets the criteria to not be defined as having a pre-existing condition, then send a letter to the HMO objecting to their denial and quote the appropriate portion(s) of the legislation. If you are still not successful in obtaining coverage, then contact your state's health insurance commissioner to determine your next course of action.