Is this legal? Private insurance exclusions

[kate86]

Hello all,

My husband and I just recently tested HIV positive. I am currently doing well with a cd4 of 1000. My husband however is pretty ill and has a cd4 of 28. He was immediately started on atripla. We have the insurance that is offered at our employer (we both work at the same place). When we went to get his atripla our "co-pay" was over $1700. After making some phone calls we have been informed that our insurance excludes all treatment related to HIV/AIDS. I was so shocked that we have been paying into something that will not cover any of his meds, or our multiple doctors appointments and labs that we have been through this past month. Are insurance companies really allowed to just not cover it? It doesn't seem like it should be legal. I am aware that there are many programs out there to help us and we did meet with a case worked today to get started on all the paperwork. Has anyone else dealt with an insurance like this?

Thanks,
Kate

[Assurbanipal]

Kate

I'm sorry but I think the answer to your question is -- it might be legal. 



It is illegal if your employer misrepresented to you what your plan covers.

But after that, it gets more complicated.  That's because some health plans are regulated by State law and some by federal law.  Some state laws don't allow a health insurance plan to exclude HIV coverage.  Prior federal law allowed a plan to provide very limited coverage or to exclude coverage for a particular disease.  While specific HIV exclusions are rare, many plans provide very small benefits aside from doctor checkups.  The Patient Protection Act (Health Care reform) will generally require that health plans offer more comprehensive coverage but the details aren't all available yet, and employers will have the option of keeping their old plans in many circumstances. 


If you feel your employer misrepresented the plan you may wish to talk to a lawyer.  Lambda legal has a free help line number and other useful info here http://www.lambdalegal.org/help/

Sorry not to provide a less ambiguous answer -- I know you are dealing with a lot right now and wish you strength.

Assurbanipal (not a lawyer)

[Ann]

Hi Kate, welcome to the forums.

That really sucks about your insurance. If it isn't illegal, it should be.

If you would rather not reveal your location on the public forum so you can get more specific advice, I suggest you send a PM (Private Message) to JR Gabbard who is this forum's moderator. You can read about who he is and why he can help here. His remit is more on the benefits side of things, but he knows a thing or two about health insurance too.

You will need to post at least one more time before you can send or receive PMs here as you must have three posts to your name in order to be able to do that.

I hope you get some sort of health coverage soon.

Ann

[JR Gabbard]

Hi Kate,

I don't really have enough information to adequately answer your question.  Are you covered through a policy with an insurance company, or is it employer self-insurance?  It would also be helpful to know what the policy description documents (that you should have received when you first enrolled in the plan) have to say.

The Americans with Disabilities Act (ADA) prohibits discrimination based on a disability.  In other words, an employer cannot use health insurance benefits to "weed out" persons with HIV.  It also means that an employer must offer you the same benefits it offers to other employees.  So if they cover other "expensive" conditions, ie cancer, but not HIV care, they may well be in violation of federal law.

US employers are not required to offer health insurance benefits to employees.  If they do, they must do so even-handedly.

I would STRONGLY encourage you to speak with an attorney in your local area, who is familiar with HIV-related legal issues.

[Ann]

I would STRONGLY encourage you to speak with an attorney in your local area, who is familiar with HIV-related legal issues.

Kate, after reading what JR has to say, I would also strongly encourage you to get in touch with a lawyer. As you probably don't know where to even start in finding one who is familiar with hiv related legal issues, you should get in touch with the organisation Assurbanipal linked you to as they will either be able to help you directly, or they will be able to point you in the right direction.

Lambda legal has a free help line number and other useful info here http://www.lambdalegal.org/help/

Good luck, and hang in there. Do not be afraid to fight this and remember, we're in your corner.

Ann