Illinois Targets Health Insurance Companies That Deny Coverage Based on “Pre-Existing Conditions”

We’ve all heard this story before – a health insurance company or HMO refuses to pay for medical treatment of a “pre-existing condition.”  As of August 26, 2011, the newly reformed Illinois Health Carrier External Review Act (“HCERA”) offers some relief.

Prior to August 26, 2011, the HCERA allowed consumers to request that the Illinois Department of Insurance review decisions made by health insurance carriers denying payment for treatment that the carriers deemed to be unnecessary, experimental or investigational, or if coverage was rescinded for a reason other than non-payment of premiums.  On August 26, 2011, the HCERA was amended so that consumers can also request review of a carrier’s determination that treatment is not covered because it relates to a pre-existing condition.

Compared with a lawsuit, the external review process is a much quicker method for overturning a carrier’s denial of coverage.  In fact, some insurance policies require that you exhaust the external review process before you can even file a lawsuit.  The process is fairly simple.  Once you have exhausted your appeals to your insurance carrier, you have 4 months to file a request for external review with the Department of Insurance.  Within 5 days of filing your request, the Department of Insurance is required to refer your case to an independent review organization (“IRO”) where a qualified medical practitioner will review any relevant materials and determine whether to uphold or overturn your carrier’s decision to deny coverage.  The IRO is required to make its decision within 45 days from the date it receives the request for external review.  If the IRO overturns the carrier’s decision, the HCERA requires that the carrier pay the disputed claims immediately.

Our firm ( recently represented a client who was insured by one of the largest health insurance carriers in the nation, Humana.  Humana refused to pay over $64,000 in medical bills for treatment that Humana deemed to be related to a “pre-existing condition.”  Our client followed Humana’s internal appeal procedures without any luck.  Our client even submitted a letter from his treating physician stating that the treatment was not based on any pre-existing condition.  However, Humana still refused to pay.   Meanwhile, creditors were hounding him to pay the claims that Humana had denied.

Our firm filed a Request for External Review with the Illinois Department of Insurance and submitted medical records and other materials to the appointed IRO showing that our client’s treatment was not related to a pre-existing condition.  In less than 5 weeks, the IRO overturned Humana’s decision, requiring Humana to immediately pay the full amount of the disputed charges.

If you feel that your insurance company has wrongly determined that your treatment was related to a pre-existing condition, was unnecessary, experimental or investigational, or if your coverage was rescinded for a reason other than non-payment of premiums, you may not have to accept that determination as final.  You may be able to request an external review through the Illinois Department of Insurance and get results in a matter of weeks instead of months or even years.

Not all claims are eligible for the external review process, and there are strict deadlines for filing your request with the Department of Insurance and to provide materials to the appointed IRO for their consideration.  So you must act quickly.

For more information on the external review process you can visit the Illinois Department of Insurance website by clicking here:  You can also call our firm to speak with one of our attorneys (