Are pre-existing conditions an automatic 'no' for private, individual health insurance?
October 29, 2010 12:55 PM   Subscribe

I'm going to be unemployed soon, and have been looking for independent health insurance as an alternative to COBRA. I'm worried about denial of coverage due to pre-existing conditions, and had questions about how likely this could be.

In the past year, I've been to the doctor for various illnesses, including multiple new chronic conditions like high blood pressure. My history in the past year is enough to require additional sheets on any application form. I'm really worried that my medical history would be used to either deny coverage, or push me to high deductible policies. For various reasons, I'd like to keep or have continuous coverage rather than have a gap.

If coverage is denied on one application, is that a black mark that other insurance companies will find out about and influence their decisions? Is there any insurer that's more or less likely to deny based on pre-existing conditions?

Also, how important is it to vet my health history via the Medical Information Bureau? How much medical history do they cover? (Do they cover prior COBRA and student health insurance?) Will insurance companies be checking against it when they process an application?
posted by anonymous to Health & Fitness (14 answers total) 6 users marked this as a favorite
Don't know the answer to those particular questions but an alternative to an individual insurance policy you should know about is, if you have your own small company or if you form one in the future, in many states insurance providers are required to offer "small group policies" to companies with only one employee. If you're on a former employer's group policy now, you have 63 days after termination of the old policy to sign on to a new group policy and if you do the HIPAA law from the nineties prevents them from excluding coverage of pre-existing conditions.

If you're lucky enough like me to live in a state where forming an LLC (limited liability company) is no more complicated than registering your car, it can be a fairly straightforward solution. One thing you have to remember to do though is file your business tax returns, even if in some years you have no income for the company; in my case, a couple of years in they started demanding copies of some IRS tax forms, even though when I first got the policy all they'd asked for was the state business registration info.

There's also a couple of things to know about under the PPACA, the 2010 healthcare reform act: there are special "High Risk Pool Plans" available in each state, though I don't know how affordable they are, and there's something called ERRP, the Early Retiree Reinsurance Program, which if you're older than 55 I believe will allow your former employer to extend COBRA beyond 18 months or whatever it is (I think that's true but I'm not entirely sure, and it's something that your former employer has to go through an application process for.) Tons of information on all of this stuff at
posted by XMLicious at 1:56 PM on October 29, 2010 [1 favorite]

Pre-existing conditions are not an automatic "no" as far as I'm aware especially if you don't have a gap. DO NOT HAVE A GAP!

Have you looked into what COBRA would cost? The Obama administration passed something which helps pay for around 60% of your health insurance premiums for the first 6 months, I believe. It may be more affordable than you think and hopefully you'll get a new job in that time.
posted by amanda at 1:57 PM on October 29, 2010 [2 favorites]

Anecdote: I recently left my old job and started at a new job on contract where there is no health insurance to be had. 27, some medical history (overweight, smoker, drinker, couple cardiac issues but nothing immediately life threatening or requiring meds or surgery.) I did a search online for health insurers, found one. Picked a plan for a $2500 deductible and cheap co-pays at $170/month. Was completely honest on the form.

In comparison, COBRA through my old work was set at $320/month, with a higher deductible and higher co-pays (20/50/100/350 for the COBRA compared to 20/20/50/200 for the private insurance.) I worried about the exclusions on pre-existing conditions as well, but within three business days I was accepted with no further questions. COBRA may be cheaper if you are getting fired or laid off, with a 60% reduction in cost. If you are quitting: full price.

Right now is probably the easiest time you will have getting insurance. Because of the health care laws getting kicked in, many insurers are doing an open enrollment period and are excluding people very sparingly. Apply for new insurance now and see.
Quoting amanda: DO NOT HAVE A GAP!
posted by Mister Fabulous at 2:10 PM on October 29, 2010

You can move to MA, where it's illegal for insurers to deny coverage based on a pre-existing condition.

I agree with the above though that pre-existing conditions are only a problem if you have a gap in coverage.
posted by reddot at 2:17 PM on October 29, 2010

In California, insurers have to offer HIPAA plans at a capped price above the usual individual premium. As long as you have no gaps in coverage, you can't be denied.
posted by hammurderer at 2:24 PM on October 29, 2010

As long as you don't have a gap in coverage that exceeds about 2 months (63 days to be exact I think) within the prior 18 months they can not impose pre-existing penalties on you. So what that said above. Just stay insured and you are fine.
posted by COD at 2:26 PM on October 29, 2010 [1 favorite]

In terms of making sure you don't have a gap in insurance, I have some advice to offer. I can't afford a comprehensive health insurance policy because of my own pre-existing conditions, but I wanted to cover my ass in case of catastrophe. I have a catastrophic policy, which covers stuff like a broken leg or car accident. It costs me about $80 a month (has gone up about $10 a year every year) and it counts as coverage so that if I ever get a real job with an affordable group plan, I can't be denied coverage. If you find that regular policies are too expensive, check into catastrophic policies for something more affordable. Mine is through Assurant Health, which is a sketchy company, but it's the best I can do right now. Definitely do a little research if you go this route.
posted by Fui Non Sum at 2:44 PM on October 29, 2010

The no gap in coverage answer is a good answer to the question "Can my insurance company deny my claims for a pre-existing condition" but it doesn't get to the problem at the heart of the matter. Yes, your pre-existing conditions may make it likely that you get turned down for a private insurance policy again and again or are only offered policies with crazy high costs. I know people who have been told that they were "high risk" and turned down for coverage for things such as anemia or planters warts... But as stated above, a gap in insurance is worse than limited insurance. Plus, if you are rejected enough times you may qualify for a state-run program.
posted by rosebengal at 2:58 PM on October 29, 2010

Gah, I forgot to explain the most important thing in my comment above - the reason to arrange for a small group policy is that small group policies are "guaranteed-issue" under HIPAA; it's not supposed to be possible for them to deny you coverage. (They can deny the creation of the group, however; I don't know how common that is but for me it was easy to establish the group.)
posted by XMLicious at 4:40 PM on October 29, 2010

Yes, well you can be turned down. I have a friend with only high cholesterol as a pre-existing condition and she was turned down. However, I believe she had a gap in coverage. You can try going through a broker who may have a better idea of what plans are more likely to take you and you can also apply to a number of plans at the same time in the hopes that if one turns you down another can accept you without that denial being "on record." The solutions and laws for insurance vary by state so its hard to give you too much specific information.
posted by Bunglegirl at 5:03 PM on October 29, 2010

I applied for a individual plan in Oregon a couple of years ago after my COBRA ran out (and I had no gap in coverage), and in the application I listed every silly reason I had visited the doctor for in the last 5 years, as requested. The only condition I was worried about being turned down for was a recently diagnosed ectopic pacemaker (my heart makes extra beats), which my cardiologist tells me is completely benign.
Anyway, I was denied, but not just for the heart thing. The reasons they listed? EVERY THING I had ever seen the doctor for, including ear infection, knee pain, abnormal pap (totally common), etc. I was essentially denied for ever having seen a doctor in the last 5 years. Who knows, maybe there's something else in my medical history that set off red flags, but instead of identifying one thing they just listed everything.
Luckily, I was eligible for a portability plan from my previous employer. The rates are high and the coverage is not as good but at least I'm covered.
So in my experience, pre-existing conditions, even just previous doctor visits, can certainly affect your ability to get an individual plan. I hope that's changed since the new health care plan has started to take effect. Our system is so broken it makes me livid!
posted by feidr2 at 5:27 PM on October 29, 2010

Be careful. When I was doing research on this last year, the rules about mandatory coverage of pre-existing conditions only applied to group plans, not individual ones. Plus that doesn't kick in until they have actually offered you a policy.

The real answer is that you won't know until you try. The advice I have heard is to go through an independent broker. There is a great deal of variation among companies in terms of their requirements - a broker will know who is most likely to insure you and can help you if you need to apply several times to get coverage. So go for it and if you don't get something better than COBRA, you can keep the COBRA. (Definitely opt in if you don't have another policy in place before the sign-up period expires.!!!)
posted by metahawk at 6:08 PM on October 29, 2010

I had the same experience as feidr2 with BCBS and a few others. Literally, I feel like I was denied because I visited a doctor who ran a series of precautionary tests because he suspected a heart arrhythmia (everything came back normal). I didn't have a gap either, I just knew my COBRA was running out from a previous employer, so I started checking out options ahead of time. Eventually I was accepted by Humana as part of the Humana One policy, which covers the basics at a little of $100 a month, so you might start there.
posted by shrimpsmalls at 6:20 PM on October 29, 2010

Just for the record, if you become unemployed now or later, the COBRA subsidy is unavailable to you. You had to have been laid off before June 1 for it to have been an option. I got laid off June 29th of this year, I took out COBRA, and I am paying the full amount for my coverage. I got no offer for the 60% off from the Federal Government.

So don't bank on that being an option for you.
posted by spinifex23 at 10:54 PM on October 29, 2010 [1 favorite]

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