Question
What is the name of your state? California
I have applied for individual health insurance plans and been denied three times, for having been prescribed Prozac. Initially, because I was taking it at the time of application and disclosed this information (the folly of honesty). (They also declined to issue a rider/exclusion/rate increase for the condition/medication.) I quit taking the medication and seeing the doctor for over a year, and still was declined because of a history of the condition/medication. Is there any limit on how long I can be frozen out of the private insurance market for taking this medication?
I don't have any other medical problems. The applications did ask if I'd ever in my entire life ever had any symptoms of such things like diarrhea or "any other symptom" of anything whatsoever, and, honesty aside, I've eaten some things in my 42 years of life that didn't agree with me later, taken antibiotics (but for what or when I cannot remember), had stiches as a kid, yet I answered "no". Is that fraud? Is that "material"? Does it matter?
I'm told I don't have any recourse with the insurers because I'm not an insured. I'm told I only qualify for the hefty-priced CA "major risk" plan (seems a bit of overkill for one prescription) that once completed, brands me for life as "major risk" at a ten precent premium increase every year, forever, over the already pricey initial enrollment.
Your thoughts appreciated.
Answer
There is nothing wrong with being honest on an application. To do otherwise is fraud, can result in claim denial and/or revoking the policy back to the effective date with premium refund.
Each carrier has their own proprietary rules for underwriting. Some will look at the most recent 12 months while others will go back further. A good agent should have access to underwriting manuals and be able to assist in determining which carriers are more liberal than others.
Most applications are broken down into time frames, depending on the severity of the injury or illness. Items such a broken bones that occurred 30 years ago without residual problems are of no concern to a carrier. However, injury or illness within the last 5 years creates more interest, particularly if there is a possibility of recurring.
If you have access to an HMO you might do better than you have in the past. While their underwriting practices can be stiff they also accept members without limits on pre-ex conditions. I have clients in GA who have a history of using antidepressants and have been able to secure coverage.
Answer
Thank you for your response. I really do appreciate it.
Unfortunately, the agents I've spoken to haven't been "good" agents then. One told me to lie on the app. (which I wouldn't do), another said I need to spend the next 2 years proving "good health" with physicals, tests, blood work, etc., (don't see how that's going to negate an antidepressant history), and the last said I was stuck with being a "major risk" for the rest of my life.
Guess I'm just going remain one of those stuck in the uninsured gap: not needy enough for assistance, not wealthy enough to afford major risk, not "qualified" for individual insurance. Sad for a physically fit, disease free, athletic individual (record of which I do have). I'll look into the HMO, but in CA there's only a couple of options left and I'm wary to apply, to exhaust the last option. Once all insurers have denied me . . . Makes a case for health care reform, I think.
Thanks still for your suggestion.
Answer
. . . Makes a case for health care reform, I think.
QUOTE]
A handful of states, mostly in the New England area, have enacted legislation such as you suggest. Carriers are prohibited from underwriting from prior health history, excluding conditions from the policy, or rating up the policy for the additional risk.
You should note that policies in these states run about 3x the cost of traditionally underwritten coverage in neigboring states.
Answer
Your thoughts appreciated.
First, this is NOT a legal question...
Second, you have NO recourse. They (as a private insurer) can choose who to do business with or not. Apparently, they have chosen to not do business with you.
Of course, if you want, you can file a claim with your state insurance commission... but I don't see any thing for them to act on.
Answer
There is indeed a legal question in there. Perhaps you didn't carefully read the post. The legal question was whether the was any limit ("legal" limit: statutory, administrative, or otherwise) in my state, as to how long one can be excluded from the individual health insurance market for a medication history. Apparently, at least in CA, the answer is no. Fair enough. Good to know, to the posters that told me so, but not a "legal" question? I don't think so.
Answer
There is indeed a legal question in there.
Okay, lets play your 'game'. These are the ONLY questions you asked in your first post:
"Is there any limit on how long I can be frozen out of the private insurance market for taking this medication?"
That is NOT a legal question.
"Is that fraud?"
You're correct. That IS a legal question. The answer is, 'No, it is not criminal fraud'.
"Is that "material"?"
Note a legal question.
"Does it matter?"
Not a legal question.
There. Feel better??
Answer
What about "OPEN ENROLLMENT". Ins. Co.'s usually offers this once a year!
I don't know the details about it, but I know that a family member of mine chose this option due to their past medical history. It did end up being less costly than a "major risk" plan, but I'm not sure by how much.
Just thought I would offer that suggestion. Maybe someone here knows more details about it!
Answer
What about "OPEN ENROLLMENT". Ins. Co.'s usually offers this once a year!
Open enrollment only pertains to enrollment periods, usually when current policyholders are allowed to amend their policy coverage.
It is NOT a 'we insure anyone who applies' policy. The insurance company is allowed, within state guidelines', to establish their policy practices.
Answer
Open enrollment is something that the employer offers and then only if the employer's group health plan is a 125B plan - that is, any premiums the employees pay are done on a pre-tax basis. Not all employers offer this benefit. If they don't, then employees who apply for coverage past their initial eligibilty date are "late entrants" and subject to the insurance carrier's underwriting standards.
Answer
I wasn't sure how it worked, that's why I suggested it! Thanks for clarifying.
Answer
Have you considered taking sabbatical in New England? If you move here for a year, may be able to get insurance, even free care if you don't have much money. Once you are back in, insurances would be much less likely to deny any enrollment, the key is to have continuos current coverage when you enroll. Then, you can move back in a year and have insurance (especially if you have national carrier, like BC/BS)
Answer
Okay, lets play your 'game'. These are the ONLY questions you asked in your first post:
"Is there any limit on how long I can be frozen out of the private insurance market for taking this medication?"
That is NOT a legal question.
"Is that fraud?"
You're correct. That IS a legal question. The answer is, 'No, it is not criminal fraud'.
"Is that "material"?"
Note a legal question.
"Does it matter?"
Not a legal question.
There. Feel better??
The name of this forum is freeadvice.com - not freelegaladvice.com
Cut some slack and stop looking at the world in black and white. It's colored you know!
Answer
TCut some slack and stop looking at the world in black and white. It's colored you know!
Since your ONLY post on this thread was to provide this random drooling.... how about your kissing my WHITE ass???