AIDS and the Law Page: 11 of 24
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sentation when you applied for the insurance. A preexisting condition is
any condition you knew you had, or should have reasonably known you
had, at the time of taking out the policy. Most policies have preexisting
condition clauses under which the insurance company refuses to pro-
vide coverage for any preexisting condition, usually for a period of six
months to one year. HMOs that are federally qualified cannot exclude
preexisting conditions. Such clauses are disfavored and will likely be
eliminated under federal health care reform, but until then the insurance
policy will pay benefits for preexisting conditions only after the speci-
fied time period elapses. If your claim is denied under a preexisting
condition clause, contact an attorney. A material misrepresentation is a
fact which you omitted on your application or answered incorrectly and
which was discovered by the insurer. The insurer may argue that you
obtained the policy through fraud and that it never would have issued a
policy had it known about the fact misrepresented. Most insurance poli-
cies do not allow the insurer to claim material misrepresentation after a
certain amount of time has elapsed.
Insurance companies also may refuse to pay claims for other reasons,
you should always consult with an attorney about these issues.
What qualifies as material misrepresentation?
Frequently, this is the failure to report that you consulted or were at-
tended by a particular physician for a particular ailment or that you have
tested positive on an HIV blood test. When the insurer claims that you
have made a material misrepresentation, it will return your policy with a
refund of the premiums you have paid. Before cashing any refund check
from your insurance company, consult an attorney. Cashing the check
may waive any rights you otherwise have to coverage under the policy.
Should I continue to pay premiums even if my insurance company
denies me coverage?
Yes. If your insurance company has wrongfully denied coverage, you
may lose your right to enforce the policy if you do not continue making
premium payments. You will certainly lose your rights with respect to
future claims. Also, your insurance company may not be under an obli-
PAGE 11
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AIDS and the Law, pamphlet, Date Unknown; (https://texashistory.unt.edu/ark:/67531/metadc1457499/m1/11/: accessed July 17, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu.; crediting UNT Libraries Special Collections.