I. Types of Health Care Plans and Health Care Insurance

II. Applying for Insurance Coverage

I. Types of Health Care Plans and Health Care Insurance

 Traditional indemnity "fee-for-service" comes in several forms, including:

• individual insurance;
• employer group plan insurance;
• non-employer group plan insurance (for example, through a professional or trade association); and
• employer funded self-insurance.

• Indemnity or "fee-for-service" plans involve traditional insurance plans. The insured person pays a monthly premium, and the plan agrees to pay all or part of the cost of covered medical services. Usually, you first pay an annual deductible (often $200 to $500), after which the plan generally pays 80% of the "usual and customary" charge for the medical services.

• HMOs are the oldest type of managed care plan. In exchange for a monthly fee, the HMO agrees to provide health care services, including preventive services such as physical exams. There is generally no "deductible" payable in an HMO, and the patient's out-of-pocket costs are minimal.

• PPOs are another form of managed care plan. PPOs provide members with a list of "preferred providers." If you go to a physician on the list, you pay either a discounted fee or a fixed co-payment per office visit. You may still go to physicians not on the list, but a PPO plan will only reimburse a portion of charges for such "out-of-network" visits, often 80%.

• Self-funded or self-insured health care plans are plans in which an employer assumes the financial risk of providing health care for its employees. Most large employers are self-insured. In a self-insured plan, the employer pays the provider directly or indirectly through an administrator. Self-insured plans may operate in the same manner as indemnity plans, PPOs, or HMOs. Significantly, federal Employee Retirement Income Security Act (ERISA) excludes self-insured plans from state regulation through the Texas Department of Insurance (TDI), or any state agency. There are only limited federal protections, most of which require employees to adhere to the terms of the plan instrument. This distinction is very important, since a patient in a self-insured plan will not have many of the protections provided by state law that govern insurance companies and HMOs. If you are unsure whether a plan provided by your employer is a self-funded plan, check with your employee benefits coordinator.

What is a "pre-existing condition"?  

• A pre-existing condition is a health condition that existed before the policy was purchased. Generally, for both group and individual insurance plans, if you have seen a physician within the previous 12 months (this period may vary in different plans) for a health condition, that particular condition will not be covered, either permanently or for a specified waiting period (usually six months to two years), or you may be refused coverage or charged a higher premium for the coverage. The National Coalition for Cancer Survivorship (NCCS) points out that cancer survivors have a pre-existing condition from the time of diagnosis through the remainder of their life, since a cancer survivor usually needs to see a physician at least once a year for a checkup.

• The federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) may protect employees with group health plans who change jobs (and therefore health plans) by giving employees "credits" against the waiting period for coverage of pre-existing conditions. For example, if you are covered by one employer's health plan for 10 months, the maximum 12 month waiting period is reduced by the 10 months you were already covered under your prior plan, so your maximum waiting period for the pre-existing condition  is two months. If you have worked 12 months or longer for the first employer, there will be no gap in coverage. No waiting periods at all may be used for coverage of pregnancy, newborns, or adopted children.

• If the HMO offers to cover a group, no group member may be denied coverage for a pre-existing condition. HMOs offering individual coverage cannot limit coverage because of pre-existing conditions, but may charge a higher co-payment for up to 12 months for services related to the pre-existing condition.

• Texas law prohibits insurance companies and HMOs from denying coverage because of a woman's diagnosis or history of a fibrocystic breast condition.

• A child subject to court-ordered medical support (for example, pursuant to a divorce decree) may not be denied coverage by an insurer on the basis of a pre-existing condition.

You should carefully disclose any pre-existing conditions, visits to physicians, hospitalizations, and other requested health care information on your application for enrollment. Even though such disclosure may result in coverage being denied, a waiting period for pre-existing condition coverage, or a higher premium, it is better to face such issues at the application stage rather than later. If you provide false information, or misrepresent your health conditions, this could result in denial of benefits or cancellation of your policy.

What is a "genetic test"?

A genetic test is a specialized laboratory test that measures your inherited traits for predisposition to a clinically recognized disease or condition. These tests are increasingly used to predict the risk of cancer. Such a test may show the relative likelihood of you eventually having the disease or condition. "Genetic test" (as defined under Texas insurance law) does not include a routine physical examination, or a chemical, blood or urine analysis.  

May a health insurer require that I undergo a genetic test as part of the application process?

Texas law provides that a group health benefit plan may require genetic tests only in limited circumstances, and must notify the applicant that the test is required, disclose to the applicant the proposed use of the test, and obtain the applicant's consent. The law does not apply to individual health insurance policies or self-insured employer plans.

May I be denied coverage based upon the results of a genetic test?  

A group health benefit plan may not use genetic information to reject, deny, limit, cancel, refuse to renew, or increase the premiums for coverage under the benefit plan. This legal restriction does not apply to disease-specific (e.g., cancer-only) policies, or to Medicare supplemental policies.  

If I am denied coverage, what options do I have?

• The Medical Information Bureau (MIB) is an organization that provides insurance companies with reports on the medical history of applicants. If you are denied coverage because of a report, you may obtain a free copy of your report by calling (617) 426-3660 or writing the MIB at P.O. Box 105, Essex Station, Boston, MA 02112.

• If you were denied coverage on the basis of a report from MIB, first obtain a copy and verify the information in the report is accurate. If there are errors, advise the MIB in writing and work with them to get the errors corrected.

• Also, try obtaining coverage from other insurance companies or HMOs. Check with business, professional, or other associations that may offer group coverage, and check governmental options such as Medicare or Medicaid.

• You may be eligible to obtain health insurance from the Texas Health Insurance Risk Pool, if you: (1) have been denied health insurance by at least two private companies, or (2) have access to insurance but it won't cover pre-existing conditions, or the rates charged are higher than the Pool's rates or (3) have been without employer-sponsored coverage for less than 63 days after having had such coverage for at least 18 months. In addition to these limits, people with certain conditions (including cancer) will automatically be accepted for coverage. The coverage costs about 50% more than other commercially available coverage. To obtain more information on the plan, contact the Texas Department of Insurance.

As with any other requested information on the application for insurance enrollment, it is best to truthfully answer the questions asked, to keep the insurer from later claiming that you committed fraud or misrepresented your health condition, and later denying coverage or canceling the policy. In any event, the insurer may learn such information from the MIB.

Who has access to the information on my insurance application?

In the application form, you will be asked to authorize the insurer to share the information with the Medical Information Bureau. The MIB will give summaries of the information to other member insurance companies who request the information.  

Do I have a right to privacy of any of the information provided or obtained in the application process?  

Any specific facts and information relating to particular policies or claims are confidential while in the possession of an insurance company, organization, association, or other entity holding a certificate of authority from the State Board of Insurance and may not be disclosed to any other person, except as specifically provided by law. Insurance companies are permitted to allow access to others within the insurance industry--see the discussion of the Medical Information Board above.  

Also, applicant information is protected from disclosure by HMOs. Any information pertaining to the diagnosis, treatment, or health of any enrollee or applicant by any HMO is required to be held in confidence and may not be disclosed to any person (without consent) except in limited circumstances such as a lawsuit or court order.  

III. Retaining Insurance Coverage  

Once I have coverage, may my insurer deny me future coverage based upon the number or amount of claims that I file?  

Group coverage-employers are not required to provide health care plans to their employees, and may legally cancel coverage for the entire group at any time. Some group policies allow the company to cancel an individual's coverage for fraud, or where you have reached the "lifetime maximum" for benefits under the policy. An insurer covering the group may not cancel an individual policyholder on the basis of (non-fraudulent) claims made. Some policies also have lifetime maximums for the amount to be paid for specific diseases or conditions.

Individual coverage must now be of the type known as "guaranteed renewable" (at the option of the policyholder). However, all policies can be canceled for failure to pay premiums, fraud, and upon reaching any lifetime payment maximum. Policies may also be canceled if the insurance company stops selling individual insurance coverage, or if the policyholder no longer lives or works in an area where the insurance company is authorized to provide coverage.  

Once I have coverage, may my insurer increase my premiums based upon the number or amount of claims that I file?  

No. Under a "guaranteed renewable" type of policy, the company cannot raise your premiums unless it raises premiums for every policyholder in the same "class" (all persons of a particular age, sex and geographic region covered that such type of policy). Group policies charge premiums based on the health expenses of all the members of the group, so any increase in premium cost would be shared among all members--not passed on to an individual policyholder.

What is COBRA?

The federal Consolidated Omnibus Budget Reconciliation Act (COBRA) may allow you (and/or your dependents) to keep your employer-sponsored health care insurance coverage for 18 to 36 months if you lose your job for any reason except "gross misconduct." COBRA may also allow you to extend your insurance if you lose coverage because of reduced work hours. COBRA does not apply to employer health benefit plans with fewer than 20 employees. COBRA coverage applies in several cases, including:

• death of a covered employee;
• termination of employment (other than for gross misconduct);
• divorce;
• employee becoming entitled to Medicaid; or
• dependent child ceases to be dependent.

• A covered employee;
• a spouse or dependent child of a covered employee; or
• a retired covered employee.

Within 60 days of qualifying for COBRA coverage (e.g. 60 days from the loss of a job), you must advise your employer that you wish to continue coverage under COBRA, and pay the entire monthly premium for the coverage (including any portion previously paid by the employer) plus an administrative fee of 2%.

How long do COBRA benefits last?

Former employees are entitled to an 18-month extension of coverage. Dependents and divorced spouses are generally entitled to a 36-month extension of benefits.  

Can COBRA benefits be extended?

Certain events, such as divorce, may extend COBRA benefits for an additional 36 months.

Can COBRA benefits be discontinued?

COBRA benefits may be discontinued in the following situations:

• An employer ceases to offer an insurance plan to current employees.
• You become eligible for another plan (unless such plan has an exclusion for pre-existing conditions-if so, you keep your original policy until the pre-existing exclusion expires).
• You apply for and obtain Medicare coverage.
• You fail to pay the monthly premiums.
• You fail to accept COBRA coverage within 60 days of becoming eligible for it.

Contact the Dallas office of the U.S. Department of Labor, Pension and Welfare Benefits Administration, at 1-214-767-6831. Also, if COBRA does not apply to your situation, or if your COBRA coverage has expired, you may be entitled to state conversion or continuation options, and should contact the Texas Department of Insurance, at 1-800-252-3439 for assistance in determining whether you may be eligible.

What is HIPAA?

The federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) contains provisions designed to assist employees who change jobs or who become unemployed. Under HIPAA, employees who meet eligibility conditions must be accepted into a group or individual plan, ensuring that their health coverage is continuous.

How does HIPAA affect my insurance coverage?  

HIPAA helps protect people with pre-existing conditions from losing coverage temporarily when they change jobs. Most health insurance policies (but not HMOs) do not cover "pre-existing conditions" for a period of 6 to 24 months. HIPAA limits these periods to a maximum of one 12-month period, and also reduces the pre-existing exclusion period by one month for each month an employee was covered by his or her old plan. For example, if you have a history of cancer, and switch from one company health plan to another because you have changed jobs, HIPAA may reduce the period of any pre-existing condition waiting periods. HIPAA may not help an employee who leaves a company that has no health plan--your new employer's health plan in this case may still impose waiting periods of up to one year before covering a pre-existing condition.

IV. Making Insurance Claims

What must I do to make an insurance claim?  

With an HMO, no claim is necessary. For many PPOs, claims-handling procedures may be very simple for matters such as routine office visits (usually handled by your physician with a co-payment by you), so long as you stay within the approved network. If you go outside the network or have traditional indemnity insurance, it is important that you follow any requirements of your policy in submitting claims, and especially time requirements.  

What can I do to improve my chances of having a claim approved?  

Be sure to check to see if "pre-certification" is required for the type of medical care you will be receiving. For example, most policies now require that any hospital stay (other than an emergency) be approved before you are admitted to the hospital. If you fail to obtain any necessary pre-certification, your plan may pay reduced benefits. However, obtaining pre-certification is no guarantee that the plan will pay all the charges associated with the treatment. Also, your plan may restrict the time or day of admission; e.g., not allowing admission over a weekend for a routine surgical procedure when the surgery will not be performed until after the weekend. In summary, you should:

• obtain pre-certification as required by your health plan;
• understand your plan's exclusions and limitations before scheduling medical treatment; and
• in the case of an emergency hospital admission, notify your health plan (insurance company or HMO) within the time period required by your plan.

Yes. Texas law requires insurance companies to pay properly submitted claims according to the following time requirements.

• The insurance company must acknowledge receiving your claim within 15 business days.
• The company may ask for additional information, including details about the medical treatment.
• The company then has 15 days after you send all requested information to accept or reject your claim.
• The company can take up to 45 days to accept or reject your claim if it sends you a notice explaining the delay.
• If the company agrees to pay the claim, it has five business days to send you a check.

If your insurance company fails to pay your claim in accordance with the above timetable, you have a right to sue to recover your claim, plus 18% damages and attorneys' fees. You may also appeal the decision internally to your insurance company or HMO in accordance with their appeal procedures, and/or file a complaint with the Texas Department of Insurance. Also, see the discussion of "Independent Review Organizations" below.

May I resubmit a denied claim?

Yes. You may resubmit a claim for review where you discover the insurance company has made an error. For example, if you (or your physician) properly obtained pre-certification for a hospital stay, and the company only paid your claim at a reduced rate, you and/or your physician should write to the insurance company and tell them the date pre-certification was obtained. Also, most insurance policies agree to pay the "usual and customary" charges for medical services, based on rates usually charged by physicians and other providers in your area. If your claim was paid at a greatly reduced rate, have your physician write a letter to the company justifying his or her charge. You could also research charges in your area by calling other specialists and asking what they charge for the same procedure, and then send a letter to the insurance company with the results of your research.

Will my health plan cover the cost of reconstructive surgery following a mastectomy?

Yes. For plans that are delivered, issued for delivery or renewed on or after January 1, 1998, Texas law mandates that a health benefit plan that provides coverage for mastectomy must provide coverage for breast reconstruction. The coverage may be subject to the same deductible or copayment applicable to mastectomy. Furthermore, a health benefit plan may not offer a financial incentive for a patient to forgo breast reconstruction or to waive the coverage of a reconstruction.

What about coverage for "experimental" therapy?

Most insurance policies do not cover treatment that is experimental or investigational. However, virtually every treatment is "experimental" when first introduced, so the issue is really whether the proposed treatment is experimental based on current information. If your doctor believes you need a treatment that the insurance company has denied as experimental, the insurance company will need to be convinced that the treatment is recommended by experts in the field, that the patient will benefit from the treatment, and that the treatment is for the patient's benefit-not just for the benefit of furthering scientific research. For more information, see Cancer Treatments Your Insurance Should Cover, published by the Association of Community Cancer Centers.

What is "medically necessary treatment"?

Both insurance companies and HMOs only cover "medically necessary" care. Texas law defines "appropriate and medically necessary" as "the standard for health care services as determined by physicians and health care providers in accordance with the prevailing practices and standards of the medical profession and community." For example, most health plans would refuse to pay for laetrile therapy to treat cancer, because it has not been shown to be safe and effective. A bone marrow transplant to treat breast cancer might be refused on the basis that such therapy is unproven in the treatment of breast cancer.

Is an insurer required to cover treatment that is not medically necessary?  

A health care plan is not required to cover treatment that is not "medically necessary." A problem may arise when your plan refuses to provide (or pay for) treatment you or your physician feel is medically necessary (such as a lab test, specialist referral, or prescription medication). The problem may arise with your physician refusing to authorize a specialist referral or test you feel is needed, or you and your physician may agree on treatment that the plan administrator won't approve.

What is utilization review?

The utilization review process evaluates requests for medical treatment and determines whether the treatment is medically necessary. State law allows HMOs and insurance companies to conduct such a review of proposed or ongoing treatment.

If the utilization review results in the denial of my claim, what recourse do I have?

If your HMO declines to provide care (or your insurance company declines to pay for care) that you feel is medically necessary, you have the right to request that an Independent Review Organization (IRO) review your health plan's decision.

What is an IRO?

An Independent Review Organization is a state licensed organization that conducts an independent, unbiased review of a health care plan's decision to deny care where a patient (or the patient's physician) believes the care is medically necessary. IROs are licensed by the Texas Department of Insurance.  

What must I do to have an IRO review my claim?

You or anyone acting on your behalf (e.g., your physician) may initiate a request for IRO review. By law, when your HMO or insurer denies treatment you have requested, your health plan is required to send you the forms and other information necessary for an IRO review. You simply complete the forms and return them to your HMO or insurer. Your health plan is required to pay for the costs of the review. If your health plan does not send you the necessary forms or advise you of the right to have your claim reviewed by an IRO, contact the Texas Department of Insurance for assistance.

If the IRO approves my claim, what happens?

If an IRO agrees your requested treatment is medically necessary, your health plan must pay for your care. Regardless of its decision, the IRO will furnish you with a notice of its decision that includes:

• the basis for the IRO's decision;
• a description of any guidelines used in making the decision;
• qualifications of the IRO personnel who reviewed your case; and
• certification that the IRO has no "conflict of interest" with your health plan which could cast doubt on the IRO's independence.

The IRO process is intended to give patients a quick and easy way to resolve denial of care disputes without the expense of going to court or dealing with corporate bureaucracy. However, if your HMO or insurance company denies medically necessary care, you may have a right to sue them if you can prove you were injured by the denial of care, even if the IRO decides against you. To file a lawsuit, you would need to get a lawyer to represent you.

Are there any other ways to get approval of a claim if my medical condition is serious?

In an emergency situation, you do not have to wait for a treatment coverage decision from an IRO. If you believe you need emergency care, the IRO process does not affect your right to seek such emergency care. If your health plan denies payment for the emergency care, you can still use the IRO process. However, if the IRO decides in favor of the health plan, you may be liable for the costs of the emergency treatment.

Where can I get more information on the IRO process?

Contact the Texas Department of Insurance IRO Information Line at 1-888-TDI-2IRO (834-2476).

V. ERISA

What is ERISA?  

The Employee Retirement Income Security Act (ERISA) is a federal law that regulates benefit plans offered by employers, such as pension plans and some health care plans. Where an employer is self-insured, ERISA excludes the plans from state regulation. For example, an employer may contract with an HMO to provide health care in a self-funded plan, and the plan will not be subject to regulation by the Texas Department of Insurance (TDI).

How do I know if I am subject to ERISA?

Check with your employee benefits coordinator.

How may ERISA affect any insurance claim I may have?

If your health care plan is subject to ERISA, you may not have the protection of state laws that regulate insurance companies or HMOs.

VI. Health Care Decision Making

What can I do to make my wishes surrounding medical treatment known?

You can (and probably should) execute a Durable Power of Attorney for Health Care, as well as a Living Will. Forms for both are found in the Texas statutes and are readily available from hospitals and many physicians. You may not need a lawyer's assistance to complete these documents, but if there is anything in the documents that you do not understand, a lawyer will be able to explain it to you. It is also very important that you alert your physicians and other health care providers about the existence of these documents.

These two documents help to ensure that your treatment decisions are known and respected, even if you should become incapacitated or otherwise unable to make the decision yourself. Texas law dictates that in the absence of these documents, decisions regarding treatment and the withdrawal of life-sustaining procedures will be left to the patient's family members who are to make the decision based on what the patient would desire, if known.

What is a Durable Power of Attorney for Health Care?

A Durable Power of Attorney for Health Care allows you (the "principal") to name another person as your "agent" to make health care decisions in the event you become incapacitated. You may execute a Durable Power of Attorney for Health Care at any time you wish. However, it will not become effective unless or until you become incapacitated (unable to understand and appreciate the nature and consequences of a treatment decision).

With the exception of your health/residential care provider(s) and their employees, you may select any competent person over the age of 18 to serve as your agent. It is a good idea to choose someone  you trust and with whom you are free to candidly discuss your wishes surrounding treatment decisions. It is also important that you discuss the Power of Attorney with your physician or health care provider before you sign it to make sure you understand the nature and range of your decisions that may be made on your behalf. You must sign the actual document in the presence of two or more witnesses. For the power of attorney to be valid, these witnesses must not be the agent, the principal's health care provider, a relative (by blood or marriage), or anyone who might inherit or be entitled to a share of your estate upon your death.

What is a living will?

A living will, known in Texas as a Directive to Physicians, is a document allowing an individual, whose death is imminent, to cause life support systems to be discontinued and be allowed to die a natural death. In addition, the individual may name an agent to make the decision for the individual if he or she becomes comatose, incompetent, or otherwise incapable of communication.

A Directive to Physicians may be executed at any time by a competent adult, but does not become effective until a terminal condition (certified by two physicians) exists and it is determined that the application of life-sustaining procedures would serve only to artificially postpone the moment of death. Moreover, the attending physician must determine that death is imminent or will result within a relatively short time without the application of life-sustaining procedures. Thus, a Directive may serve as your final expression of your legal right to refuse unwanted medical and surgical treatment and to accept the consequences from that refusal.

Like the Durable Power of Attorney for Health Care discussed above, a Directive to Physicians must meet certain legal requirements to be valid. It has similar requirements for witnesses (e.g., not related by blood/marriage, not entitled to inherit, etc.)

Will I be able to get pain medication if I need it? What if my doctor is reluctant to prescribe pain medication for me?

Yes. The Intractable Pain Treatment Act is a Texas law that protects physicians from disciplinary action for prescribing or administering otherwise dangerous drugs or controlled substances in the course of treatment of a person for intractable pain. "Intractable pain" is defined as "a pain state in which the cause of the pain cannot be removed or otherwise treated and which in the generally accepted course of medical practice no relief or cure of the cause of the pain is possible or none has been found after reasonable efforts."

The proper relief of chronic pain is a matter between the individual physician and his or her patient. There was, at one time, a perception among physicians that they would be subject to discipline by the State Board of Medical Examiners for prescribing narcotic relief for chronic pain. However, many physicians are now aware that the board's primary concern is that narcotics stay with the patient for whom they are prescribed and are not diverted for use by others. If you feel your pain control needs are not being met properly, you may want to consult a palliative care specialist, who can often be found in major cancer hospitals.

VII. Employment Questions  

What is the Americans with Disabilities Act?

The Americans with Disabilities Act (ADA) is a federal law that prohibits discrimination against individuals with disabilities. Employers with 15 or more employees are covered by the ADA.

If my employer discovers that I have cancer, can I be fired?

No. An employer cannot terminate an otherwise qualified employee on the basis of the employee's disability. A person who is substantially impaired in one or more major life activities is considered "disabled" under the ADA. Cancer is a "disability" for purposes of the ADA, so individuals with cancer are protected by the ADA.

The ADA also prohibits discrimination against associates of individuals with disabilities. For example, it would be illegal for an employer to terminate an employee whose spouse has cancer based on fears that the added stresses or time demands would affect the employee's performance or attendance or would result in higher health care costs.

Can I be fired because cancer prevents me from working?

Perhaps. The ADA requires that employers make "reasonable accommodations" for "otherwise qualified" employees. An "otherwise qualified" employee is one who can perform the job's essential functions, with or without reasonable accommodations.

Employers are only required to accommodate individuals who make their disabilities known to their employers and let their employers know that some accommodation is required. Moreover, if an employee requests an accommodation, the employer my request documentation of the employee's disability (if the disability is not obvious).

What if I want to continue working, but I can only do so part time?

It is possible that job restructuring could be a reasonable accommodation. However, work attendance is generally considered to be an essential job function, and an employer may not be required to accommodate an employee's sporadic attendance over a prolonged period of time. While employers must provide reasonable accommodation, they are not required to incur "undue hardship." What constitutes undue hardship depends on the cost or inconvenience of the accommodation, and the resources of the employer. For example, reassignment of job responsibilities may be less burdensome to a large company with more personnel than to a smaller business with only a few employees in each position.

An additional consideration is that a voluntary acceptance of part-time work may jeopardize some or all of your employee benefits. You may want to consult an attorney to determine if a reasonable accommodation could allow you to work enough hours to maintain your benefits.

Is there anything I can do to keep my job?

Check with your Human Resources department about your company's sick leave policy and what accommodation to your illness the company can make. They may provide some financial benefits while you are unable to work. Additionally, if you have disability insurance, and if you qualify, your Human Resources department can help you apply.

What is the Family and Medical Leave Act?

The Family and Medical Leave Act is a federal law that protects employees who must take leaves of absence because of family or medical emergencies. The law requires employers with 50 or more employees to provide eligible employees with unpaid leave for up to 12 weeks for the birth or adoption of a child; the care of a seriously ill child, spouse, or parent, or the employee's own serious illnesses.

To qualify, the employee must have worked for the employer for at least 12 months and 1250 hours during the 12-month period. The 12 weeks of unpaid leave may be taken intermittently during a 12-month period. In some circumstances, employers can require employees to use accrued sick leave or vacation before the unpaid leave begins.

I believe my cancer may have been caused by exposure to toxic substances at work. What rights do I have?

Most employers carry workers' compensation insurance, which provides benefits for employees injured or made ill while in the course and scope of their employment. There are strict requirements that must be met before one qualifies for workers' compensation insurance for cancer treatment. First, you are required to report your illness to your supervisor within a reasonable (but short) period of time after it is diagnosed. Next, you must be prepared to prove that your cancer was caused by something you were exposed to while in the course and scope of your employment, and not other factors such as genetics, personal habits such as smoking, etc.

If you believe your cancer was caused by a work-related condition, you should consult an attorney. Additionally, Texas law provides for an ombudsman program to assist workers and their families. These people assist unrepresented claimants and other parties to make sure their rights in the Worker's Compensation system are protected. All employers are required by law to notify their employees of the ombudsman program.

VIII. References and Additional Resources

Agency for Health Care Policy and Research (AHCPR), Choosing and Using a Health Plan, Executive Office Center, Suite 501, 2101 East Jefferson Street, Rockville, MD 20852. 1-800-358-9295.

American Cancer Society, 1-800-ACS-2345. Managed Care and Cancer Control.  http://www.cancer.org

Association of Community Cancer Centers (ACCS) Cancer Treatments Your Insurance Should Cover, 11600 Nebel Street, Suite #201, Rockville, Maryland 20852.

Consumers' Checkbook Consumer's Guide to Health Plans 1-800-475-7283, http://consumer.checkbook.org/consumer/health/hmo.htm

County Indigent Health Insurance: Check with the local county courthouse.

Health and Human Services In Texas: A Reference Guide (available at some public libraries-contains detailed information on federal and state health care programs).

Medicaid: 1-800-252-8263

Medicare: 1-800-772-1213

National Coalition for Cancer Survivorship (NCCS) What Cancer Survivors Need to Know about Health Insurance, 1011 Wayne Avenue, 5^th Floor, Silver Spring, MD 20910. (301)-650-8868.

National Committee for Quality Assurance (NCQA) Choosing Quality: Finding the Health Plan That's Right for You (NCQA's Guide for Consumers). 1-888-275-7585, http://www.ncqa.org/consumer.htm

Office of Public Insurance Counsel (OPIC), 333 Guadalupe Street, Suite 3-120, Austin, TX 78701, (512) 322-4143.

Texas Department of Health: 1100 West 49th Street, Austin, Texas 78756-3199. The phone number is 512-458-7111 512-458-7714 (hearing impaired) http://www.tdh.state.tx.us/

Texas Department of Insurance Questions and Answers about Your Health Care Coverage 333 Guadalupe, Austin, TX 78701 (Mail - P.O. Box 149104, Austin, TX 78714-9104). (512) 463-6169 or 1-800-578-4677 http://www.tdi.state.tx.us/index.html

Texas Rehabilitation Commission: 512-483-4067 1-800-628-5115 (hearing impaired)

Veterans Administration: 1-800-827-1000