State RegulationsTX specificDifficulty 2/5
A Texas group health plan covers a covered employee's newborn from birth. The baby is born with a serious congenital heart defect, and the insurer denies the hospital claim on the ground that the defect is a pre-existing condition. Which statement is correct under the Texas newborn coverage requirement?
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Answer & full 3-part explanation (select an option above, or peek)
Why B is correct
Under TIC 1367.003 and 28 TAC 3.3403, coverage of a newborn child from birth includes the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. An insurer therefore cannot defeat a newborn's claim by recharacterizing a birth defect as a pre-existing condition, because the child has been covered from the instant of birth and the congenital-defect coverage is part of the mandated benefit.
Why the other options are wrong
- A) Nothing in the statute conditions the coverage on when the defect was diagnosed; a defect diagnosed after birth is covered.
- C) A condition that exists at birth is exactly what the congenital-defect portion of the newborn mandate covers, so it cannot be excluded on that ground.
- D) Enrollment is not a precondition to the child's coverage, which is effective from birth and reaches the treatment of the defect.
Memory hook
Newborns are covered from birth, and birth defects come with them.