What Do You Mean It's Not Covered: A Preexisting Condition Dispute
The 1993 Ohio case -- Shelley Svec v. Enterprise Group Planning, Inc. -- illustrates just how difficult the term "preexisting condition" can be. (It also highlights the role of third-party health insurance administrators _ a form of insurance provider whose numbers are growing.) Svec's coverage under the group medical insurance policy became effective October 18, 1988. She was treated by Dr. Michael Papsidero for various medical conditions from 1986 to the effective date of her insurance. Papsidero had treated Svec for recurrent rhinitis and sinusitis on two occasions in April 1988. Her treatment on April 25, 1988 fell within the six-month exclusionary period of her group medical insurance coverage administered by Enterprise. Svec started work at Research Organics, Inc., on August 18, 1988 and completed a group medical insurance enrollment card and individual enrollment supplement which didn't refer to the above medical conditions.
The group enrollment card, which Svec completed and signed in August 1988 -- prior to obtaining coverage under the Research Organics, Inc.'s group medical insurance plan, stated in relevant part: I hereby request coverage under the policy issued by Cincinnati Equitable Insurance Company and authorize my employer to deduct from my earnings any requested contribution for the insurance to which I am or may be entitled.... I understand that if the insurance applied for becomes effective, I will be subject to all the terms of the policy, that the agent is not authorized to alter any terms of this application or the policy and that any conflicts will be resolved solely by reference to the policy. Enterprise received Svec's group enrollment card October 17, 1988 and approved coverage for her under the Research Organics, Inc. group medical insurance policy effective the following day.
The group medical policy contained the following exclusion for expenses arising from conditions which existed prior to the effective date of the policy (the "Preexisting Condition Exclusion"):
How One Policy Handled Preexisting Conditions
Unless specific exception is made, the provisions of this policy do not include as covered charges, or provide benefits for, charges incurred in connection with: .... any charges in connection with a preexisting condition. Any injury or sickness or a related injury or sickness for which an insured individual has consulted with a licensed physician or dentist or received any medication or dental care or services within the 6 month period immediately preceding the effective date of insurance, unless incurred after the expiration of a period of:
... 6 consecutive months after the effective date of insurance during which such insured individual has not consulted with a licensed physician or received any medical care or services for such injury or sickness or related injury or sickness.... Svec received treatment from Papsidero six additional times for the same condition, including two extensive treatments in March 1989, for which she sought reimbursement from Enterprise under the group medical insurance policy. The preexisting condition exclusion applied to Svec's claim for reimbursement of the March 1989 treatments by Papsidero, since she had received treatment for this same condition within six months prior to obtaining coverage under the group medical policy and six consecutive months without any treatments for the condition had not elapsed prior to undergoing the subject treatments. Simply stated, the exclusionary period ran from April 18, 1988 to April 18, 1989. Svec had no coverage for preexisting conditions under the terms of the policy for this period. Svec claimed that she did not receive notice of this preexisting condition exclusion. Neither the group enrollment card nor the individual enrollment supplement completed by Svec prior to obtaining coverage under the group medical policy specified the scope of medical insurance coverage under the policy or stated any exclusions from coverage. Svec requested medical insurance information from her employer's personnel officer, Marilyn Garrett. Garrett gave her only one piece of literature concerning the group medical insurance policy and informed Svec that she was given "what you are entitled to have."
