OCT 27 1992

The Honorable Phil Gramm
United States Senator
2323 Bryan Street, #1500
Dallas, Texas 75201

Attention: Clarissa Clarke

Dear Senator Gramm:

        This letter responds to your inquiry on behalf of (b)(6)
concerning limitations on insurance coverage and
the applicability of the Americans with Disabilities Act to her
situation.

        The Americans with Disabilities Act (ADA) authorizes the
Department of Justice to provide technical assistance to
individuals and entities having rights or obligations under the
Act. This letter provides informal guidance to assist your
constituent in understanding the ADA's provisions. However, it
does not constitutes a legal interpretation, and it is not
binding on the Department.

        The provisions of the ADA applicable to insurance company
practices are somewhat limited, and are set forth in Section
36.212 of the Department of Justice's title III regulation, a
copy of which is enclosed. The provision appears on page 35596,
and additional discussion on this issue is included in the
regulatory preamble on pages 35562-3. Also enclosed is a copy of
our title III Technical Assistance Manual, which includes
information on this point on pages 18-9.

        We are unable to determine from the information provided
whether the situation described by Ms. (b)(6) is a potential
violation of title III of the ADA. If, after reviewing the
enclosed information, Ms. (b)(6) believes there may be such a
violation, she can proceed to remedy it by proceeding as
described on pages 64-7 of the Manual.

cc: Records; Chrono; Wodatch; Breen; McDowney; FOIA; MAF.
    :udd:jonessandra:ada.gramm2
01-01655
                                - 2 -
        There is also a possibility that Ms. (b)(6) may have a
claim under title I of the ADA, which is enforced by the Equal
Employment Opportunity Commission. It is clear from her letter
that she has already forwarded the information to the EEOC, and I
assume that she will hear from that agency concerning the
title I ADA provisions that may apply.

        I hope this information assists you in responding to your
constituent.

                                        Sincerely,

                                      John R. Dunne
                                Assistant Attorney General
                                   Civil Rights Division
Enclosures (2)
01-01656Security 80/100

A COMPREHENSIVE MAJOR MEDICAL INSURANCE PLAN

        FOR INDIVIDUALS AND SMALL GROUPS

        ONE TO FOURTEEN LIVES

        NO PARTICIPATION REQUIREMENTS

        NO CONTRIBUTION REQUIREMENTS

        SIMPLIFIED UNDERWRITING

        FEW INDUSTRY RESTRICTIONS

        RIDERS AND WAIVERS AVAILABLE

        COMPANY BEST RATING A+ (SUPERIOR)

        MATERNITY

        PREVENTIVE MEDICAL CARE

     ADMINISTERED
         BY                                      UNDERWRITTEN BY
PROFESSIONAL BENEFITS                     DURHAM LIFE INSURANCE COMPANY
   ADMINISTRATION                             RALEIGH, NORTH CAROLINA
   P.O. BOX 31810
  DALLAS, TX 75231                           A+ SUPERIOR BEST RATING
01-01657
EMPLOYEE: All full time employees on the company payroll and working a minimum 
of 30 hours per week or more.

NEW EMPLOYEES: First of the month following the completion of one month full 
time employment.

DEPENDENT: Whenever used herein shall mean - (A) An employee's spouse and (B) 
unmarried child(ren) including stepchildren, legally adopted children, or
foster children who have the same legal residence as the employee, who have
not attained their 19th birthday, and who are not members of the armed forces;
provided that any child over age 19, but less than 25, shall be considered as
a dependent only if he is attending an accredited institution of learning as a 
full-time student and is primarily dependent on the employee for support and 
maintenance and claimed as an income tax deduction.

GENERAL EXCLUSIONS: Charges for eye glasses, eye refractions and hearing aids, 
alcoholism or drug addiction, miscarriage, abortion, confinement or care in
any government hospital or institution, charges in connection with war or an
act of war or participation in a riot or insurrections; or self-inflicted
injuries, or sickness, or an attempted suicide, while sane or insane;
exogenous obesity; and any other expenses not necessitated by an accident or
sickness, including male or female sterilization or reversals thereof, whether
voluntary or otherwise. Charges for illness or injury arising out of the
Military Service; charges which a person is not legally required to pay;
treatment of corns, callouses, bunions, trimming of toenails except as
provided in the Policy. Service or treatment due to altering the size or shape
of the breast, or any other anatomical part of the body, male or female,
whether voluntary or otherwise.

Any care or treatment of the teeth or gums or for the fitting or wearing of 
dentures; or any care or treatment of teeth, jaws, or jaw joints, including,
but not limited to: atrophy of the lower jaw; malocclusion; maxillo-facial
surgery; tempero-mandibular joint dysfunction; and retrognathia; except for
treatment of a congenital anomaly in a child born while the person is insured
for Medical Expense Benefits under this plan. However, with respect to Section
11 - Benefits - Employee - Part EDMM - Employee and Dependent Major Medical
Expense Insurance, this exclusion shall not apply to treatment of accidental
injury to sound natural teeth (including their replacement) if the injury
occurs while insured and the treatment is given within six months after the
date of the injury. Charges incurred for a deviated nasal septum, unless
sustained in an accident which occurs while the person is a covered person
under the Policy.

GENERAL LIMITATIONS: Charges for Jaw, Dental and/or Cosmetic treatment or 
Surgery, except for charges resulting from an accident occurring while insured 
hereunder, and except for congenital defect in a newborn child. Psychiatric 
treatment out of hospital will be limited to a benefit of 50% of the eligible 
charge for treatment or consultation, up to a maximum eligible charge
of $30.00 per treatment or consultation. Lifetime maximum of $5,000 on mental 
and nervous conditions for covered expenses incurred in and/or out of
hospital. Charges for any care/service or supplies provided in connection with
hernia, tonsillitis, adenoids; any disease or disorder of reproductive system,
gall bladder, tuberculosis, cancer, tumor, varicose veins or rectal disease
will not be considered eligible charges unless such charges are incurred 
after the end of 6 consecutive months, during which the medical expense
benefits have continuously been in force for the covered person; provided,
however, the covered person has satisfied all other conditions of the policy
including the Pre-Existing Condition Limitation. Benefits payable for all
charges for or in connection with an organ transplant are limited to a
lifetime maximum of $25,000. No benefits are payable for charges related to
the donor or for the organ itself. The maximum for all benefits payable while
the person is a covered person under the policy for care or treatment related
to or resulting from Acquired Immune Deficiency Syndrome (AIDS), on and after
the date such disease has been diagnosed, shall be $10,000. For the purposes
of this provision, care or treatment shall include, but not be limited to,
care or treatment of conditions such as Kaposi's sarcoma, pneumonia,
pneumocystitis, viral diseases, and other infectious diseases, but shall not
include care or treatment of any disease or injury which is clearly not
related to the person having contracted or having AIDS. Preventive medical
care: $200 maximum per family per year; includes immunizations, mammograms,
routine physicals and pap smears.

Hospital charges incurred on Friday, Saturday or Sunday in connection with an 
admission on any of those days are excluded unless the admission is for:

        (a) an emergency condition requiring immediate medical care: or
        (b) diagnostic tests or procedures, or surgery if performed within 24 
hours from the time of admission.

RATE CHANGE: Based on claims experience - Any premium due date with 30 days 
advance written notice after completion  of selected rate guarantee. Rate 
guarantee not valid if medical history provided is not complete and accurate.

TERMINATION: By Class - Non-payment of Premium - Material Misstatement.

LIFE INSURANCE CONVERSION POLICY: If application is received within 31 days of 
employment termination.

EXTENSION OF BENEFITS: Covered Medical expenses as a result of injury or 
sickness originating prior to the dates of termination of employment will be
payable up to 12 months after termination providing the insured is wholly and
continuously disabled as a result of such injury or sickness from the date of
termination of employment to the date of incurred expense, however no benefits
are payable for expenses incurred more than 3 months after termination of
insurance with respect to the participating employer, or after the master
policy terminates, or the date you or your dependents are covered under any
other group plan, whichever occurs first.

                INSTRUCTIONS: PROCEDURE FOR SALE AND ENROLLMENT
1. Fill out name of company and "Date & Presented By" spaces on cost
calculation page.
2. Select and circle plan of life and medical coverage and any optional plans
of coverage desired.
3. Enter name, ages and dependent status for each employee on cost calculation 
page.
4. Use rates for proper coverage by age and dependent status and enter on cost 
calculation page.
5. Carry all rates totalled by benefit to the bottom of the cost calculation 
page.
6. Enter totals of columns one (1) thru four (4) and bring these figures to
the right hand side of the cost calculation page under "PREMIUM SUMMARY"
heading.
7. Add the $15.00 billing charge and the $1.00 per employee participation fee.
8. Total these figures. This total will be the first month's remittance and
must be submitted with the application.
9. Complete the Employers Agreement and Subscription to the Trust and the
agents statement which is on the reverse side of the cost calculation page and
obtain the employers signature in the space provided.
10. Separate the cost calculation/Employers Agreement from the Outline of 
Benefits page and mail this page with the completed enrollment cards, a check
for the first month's remittance, and include all material as requested by the
underwriting requirements to:

Professional Benefits Administration, Inc. P.O. Box 31810 Dallas, Texas 75231 
214-349-1996

REV.8/89

01-01658September 10, 1992

STATE BOARD OF INSURANCE
P. O. Box 149091
Austin, TX 78714-9091

I applied for medical insurance with a group at the office. A period from
about June 19th - August  6th, 1992 went by, along with an incurred cost to me
to release medical records, and postage to cover our numerous correspondence.
Finally a notice was sent stating the following "we must respectfully decline
coverage on this applicant due to medical and underwriting regulations". 
Would this not be in writing somewhere under the General Exclusions or General
Limitations in the handbook? Upon asking the agent over the phone if there was
a medical or regulation  number, she replied that she along with her head
underwriter had decided this over the phone, and that there was nothing in
writing to be seen. I HAD BEEN COMPLETELY HONEST AT THE OUTSET WITH
THEM...COULD I NOT EXPECT THE SAME?
 
It was explained to me that since I had sustained a spinal cord injury 20
years ago, and that I am  ambulatory they could not risk protecting me from
falls... CAN THEY ASSUME THAT I AM  GOING TO FALL? They were going to exclude
my lower extremities and my back, but since I am ambulatory, they could not
risk against falls. Can't they cover me for a cold, or  virus? I had a
complete physical last year, with excellent results -- above the average as a
matter of fact. My condition has been stable for some time now, and I am in
great condition.

I had insurance for 13 years with Prudential, and took my policy portable when
I left my previous employer. After the second premium didn't arrive in the
mail at my address, consequently I was cancelled with no notice--it was my
word against the mail carriers, I guess. Here again my fate is  decided over
the phone. 

First of all, I am just wondering about some kind of pre-existing time frame
on insurance. Not that I am planning in any way to take advantage of the
coverage I can get -- I never have and never will. I do occasionally catch a
cold or virus that perhaps an able bodied person passed on to me. I just want
the peace of mind to know that if something catastrophic does happen, I would
be covered. The least they could do would be refund the money that I paid to
have my records  released, knowing they were not going to cover me from the
beginning.

I am wondering how this cannot be discrimination. It might help if someone 
would come out first  hand to take the application and see whose fate they're 
deciding upon. In light of the Civil Rights  Act of 1991, and the ADA
(Americans with Disabilities) Regulations, treatment should be getting  better
to those of us making a significant contribution to society. NOW I AM FORCED
TO USE THE TAXPAYERS DOLLARS FOR HEALTHCARE, AND I WOULD RATHER USE MY OWN 
MONEY.

Respectfully submitted,

(b)(6)
Dallas, TX

Enclosures

cc: DEPARTMENT OF JUSTICE; Washington, DC
    EEOC REGULATIONS DEVELOPMENTS; Washington, DC
    CONGRESSMEN & SENATORS
01-01659