Issued and entered November 20, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On September 24, 2002, Petitioner, XXXXXXXXXXXXX filed a request for external review with the Commissioner of Financial and Insurance Services (Commissioner) under MCL 550.1901 et seq., the Patient’s Right to Independent Review Act. After a review of the material submitted, the Commissioner accepted the request. The issue involved in this matter is contractual. The Commissioner reviews contractual issues under MCL 550.1911(7). As a result, review by an independent review organization is not required. The Commissioner notified Fortis Insurance Company (Fortis) of the request for external review and requested the information it used to make its adverse determination. On October 10, 2002, the Office of Financial and Insurance Services (OFIS) received Respondent’s file information.

II
FACTUAL BACKGROUND

Petitioner applied for coverage under a short-term medical policy through John Alden Life Insurance Company, administered by Fortis. On February 7, 2002, Petitioner faxed his application for coverage to Fortis, who processed the application and made the policy effective on February 8, 2002 (the day after Petitioner first received treatment).

Petitioner seeks coverage for claims related to emergency care and hospitalization at XXXXXXXX Hospital between February 7, 2002 and February 9, 2002. However, Respondent denied coverage for Petitioner’s emergency care and hospitalization citing the “pre-existing condition limitation” in the policy.

III
ISSUE

Did Respondent comply with the terms of its Certificate of Insurance and Michigan law when it denied Petitioner’s claim?

IV
ANALYSIS

Petitioner’s Argument

Petitioner argues the emergency care and subsequent hospitalization are not related to a pre-existing condition. On the evening of February 7, 2002, he suddenly fell unconscious. His neighbor called for an ambulance and he was transported to the hospital.

Petitioner argues his treatment was during the policy coverage dates as the policy date is February 7, 2002. He believes Fortis is responsible for providing coverage for the treatment and care he received from February 7, 2002 through February 9, 2002.

Respondent’s Argument

Fortis acknowledges it received Petitioner’s faxed application for coverage on February 7, 2002. Upon receipt of claims for Petitioner’s emergency care and subsequent hospitalization, Fortis denied coverage citing the policy’s pre-existing condition clause which states:

PRE-EXISTING CONDITION: A Sickness, Injury, disease or physical condition:

1. for which the Covered Person received medical treatment or advice from a Physician within the one year period immediately preceding the Effective Date of Coverage; or
   
2. which produced signs or symptoms within the one year period immediately preceding the Effective Date of Coverage.
   
   The signs or symptoms must have been significant enough to establish manifestation or onset by one of the following tests:
   
   1. The signs or symptoms would have allowed one learned in medicine to make a diagnosis of the disorder; or
      
   2. The signs or symptoms should have caused an ordinarily prudent person to seek diagnosis or treatment.

Fortis reviewed Petitioner’s medical records and noted he went to a medical center on XXXXXXXXX due to difficulty breathing. He received a breathing treatment, felt better, and then went home. This treatment was one day prior to his application for coverage and one day prior to the date he received emergency care.

Fortis argues Petitioner suffered from chronic asthma and had chest x-rays that were consistent with chronic obstructive pulmonary disease. In addition, Petitioner was prescribed asthma medications XXXXXXXXX and XXXXXXXXX.

Respondent cites its policy regarding policy effective dates:

EFFECTIVE DATE OF COVERAGE/EFFECTIVE DATE: A Covered Person’s Effective Date of Coverage is the day after the Certificate Date.

CERTIFICATE DATE: The certificate date is the later of: a) the date You request on the Enrollment Form provided this is no more than 30 days in the future, b) the day of the postmark date affixed by the U.S. Post Office*, or c) the date the Enrollment Form is received by electronic submission…

Fortis states Petitioner’s application for coverage was received by fax (electronic submission) on February 7, 2002. In accordance with the policy language, the policy became effective the day after the certificate date. Therefore, Petitioner’s policy became effective on February 8, 2002, the day after he received emergency medical care.

Based on their review of the medical records, Fortis believes Petitioner had the pre-existing condition of asthma during the period immediately preceding February 7, 2002. Further, Petitioner’s coverage was not in force until the day after medical care was received.

Commissioner’s Review

Respondent cites two reasons in denying Petitioner’s claim: 1) Petitioner’s policy was not in effect on the date he became ill, and 2) Petitioner’s illness was a pre-existing condition excluded from coverage under the policy. Each reason is examined below.

1. Policy not in effect

Petitioner fell ill on February 7, 2002. His neighbor found him on the floor of his apartment, not breathing. He was taken to XXXXXXXX Hospital emergency room and was later admitted for two days. He applied for a short-term health insurance policy with Fortis on February 7, 2002. Under the provisions of Respondent’s policy, coverage begins on the date following the application date. Thus, assuming Petitioner has any coverage in this matter, coverage would not begin until February 8, 2002.

2. Pre-existing Condition

Fortis also asserts that the Petitioner’s condition was pre-existing at the time he applied for coverage and was hospitalized. The definition of “pre-existing condition” under the Fortis contract is clear. It includes, “Sickness, Injury, disease or physical condition: for which the Covered Person received medical treatment or advice from a Physician within the one year period immediately preceding the Effective Date of Coverage; or which produced signs or symptoms within the one year period immediately preceding the Effective Date of Coverage.” In the case at hand, Petitioner’s medical history identified his chronic asthma. In fact, the February 7, 2002 hospital medical records noted:

CHIEF COMPLAINT: Shortness of breath/asthma attack.

This is a male… with a past history of chronic asthma and past history of hospitalization for asthma in XXXXXXX, XXXX who presents to XXXXXXXXXX EC last evening via EMS from an episode of shortness of breath which resulted in the patient passing out. The patient states that he has had difficulty controlling his asthma over the past weeks and this has gotten progressively worse. He states yesterday morning he visited a Med Clinic due to his shortness of breath. [emphasis added]

This medical record clearly demonstrates the Petitioner knew he had chronic asthma and he sought treatment one day prior to applying for coverage through Fortis. The medical record also links his asthma treatments with the emergency room diagnosis; so it is clear he was admitted to the hospital as a result of an asthma attack. These facts establish a pre-existing condition and they trigger the “pre-existing condition” exclusion.

Conclusion

The Commissioner finds that a pre-existing condition was present when Petitioner applied for coverage with Fortis. As a result, Fortis is not required to pay for the February 7, 2002 through February 9, 2002 hospital services in this matter.

V
ORDER

The Commissioner Orders the Fortis Insurance Company adverse determination is upheld. Fortis is not required to pay for the February 7, 2002 through February 9, 2002 medical services in this matter.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the Circuit Court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.