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About Health Insurance Coverage Denials

One of the most frustrating aspects of buying individual health insurance is the fact that those who need it most often find it impossible to obtain. Pre-existing conditions and past denials of coverage can often mean going without insurance or being asked to pay premiums that make insurance unaffordable.

  1. Pre-Existing Conditions

    • When health insurers deny coverage, the most common reason is pre-existing conditions. The definition of "pre-existing condition" is hazy enough to see why it disqualifies many people from purchasing individual health insurance: a pre-existing condition is often defined as a condition in which you have been diagnosed or sought treatment for in the past. Therefore, a pre-existing condition can be anything from acne to cancer, and often includes such common conditions as high blood pressure, diabetes and pregnancy.

    Statistics

    • The rate at which pre-existing conditions result in insurance coverage denials is staggering. A 2010 report by the U.S. House Committee on Energy and Commerce found that the four largest for-profit health insurers in the United States have been turning down more and more applicants in recent years. In fact, from 2007 to 2009, 600,000 people were denied coverage due to pre-existing conditions. By 2009, the report found, one in seven applicants was denied coverage.

    Denial Through Premiums

    • Simply denying coverage is the most obvious way insurers restrict policies to those who have pre-existing conditions. The other way is to offer policies that are unaffordable for most people. Either by charging huge upfront premiums, building huge deductibles into the policy, refusing to offer prescription drug coverage, or restricting physician visits, insurers deny coverage to those with pre-existing conditions, or those whose age or lifestyle makes them more likely to use health insurance.

    Denial of Coverage for Specific Conditions

    • Even with a pre-existing condition who can afford an individual health insurance plan often take the insurance knowing that it's not going to cover their pre-existing condition. Health insurers will often offer coverage with the caveat that the expensive pre-existing condition will not be covered; in other words, coverage is denied for any pre-existing condition, while other conditions are covered. This denial of coverage may include routine health care for the pre-existing condition, any tests needed for diagnosis, and prescription medications.

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