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Can an HMO claim that surgery is not covered under COBRA?

Glendale, CA |

I'm helping a friend determine whether they should refute a claim by Kaiser's that because his account shifted to COBRA after a layoff, they can no longer perform a double hip-replacement surgery his Kaiser doctors told him weeks ago that he urgently needs.

The reason, they say, is that now that he's a COBRA patient, they have no way of guaranteeing that he'll continue his coverage following surgery and it would be medically negligent of them to allow the surgery to go forward if there's any chance he won't make hi follow-up visits.

So the timeline is:
Three weeks ago: Prescribe urgent surgery.
Last week: Laid off.
This week: Enroll in COBRA and be told that they won't pay for surgery because of COBRA.

Is this legal?

Per the insurer, they say that when they learn a patient is a COBRA payer, they shift his care into "maintenance mode." In the case of this friend, it means he can have all the pain meds he wants, but the surgery they've prescribed will now be denied as long as he remains a COBRA payer. Is this common? Is it true to the intent of the COBRA law, where a patient must be provided the identical access and coverage as someone still employed?

Attorney Answers 1

Posted

COBRA is "continuation coverage," which means the coverage is the same as current employees. Your friend should consult an attorney so that he or she can appeal the denial of benefits.

This answer is provided as a general opinion to a question posted on an internet forum. This does not create in either party the expectation that an attorney-client relationship has been entered into between the original poster and the answering attorney. Any information provided should not be taken as legal advice but in the context of general information. Please seek legal representation for any specific legal questions.

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