Health Insurance Denials: When One Door Closes, Look for Other Open Doors

What to do when you're deniedPresently, insurance companies can still deny medical coverage to adults, based on their health status. This will change in 2014 when the Affordable Care Act law that prohibits denials due to pre-existing conditions is fully implemented. For now, only children under age 19 are protected by the mandate.

A Mother’s Story
Recently, a parent shared her adult sons’ frustrations in trying to get health coverage with Kaiser Permanente. Debra’s son was born at Kaiser Permanente and had been a member for well over 25 years. He was covered under his parents’ group insurance but was cancelled when he reached the maximum age limit for dependent coverage. When he tried to get his own Kaiser individual health plan, he was denied due to all the prescriptions he was taking. Per Debra, “(My son) was taken care of by Kaiser for several years… you helped him through things. Now that he has to get his own plan, you refuse to let him be a patient for something that has been ongoing for numerous years. What has happened to Kaiser Permanente? The more money you get, the worse you have become! It looks like discrimination by an insurance company that had this person as a member his whole life and now you’re too good for him?! Shame on Kaiser and whoever it was that sent my son that degrading letter!”

In the case of Debra’s son, the only way he could get coverage with Kaiser Permanente was to enroll on an employer-sponsored policy. Since that was not an option, he was forced to consider getting insurance outside of Kaiser Permanente. This was especially traumatic as he lost the doctors and medical support that he had trusted for many years.

I’m sick and can’t get coverage!
If you are experiencing difficulty getting health insurance, one of the best things you can do is get informed. Find out what options are available. Here are some ideas:
Short Term Insurance. You don’t have to be uninsured while you are looking for coverage or waiting to be approved. If you were denied coverage for a standard health plan, consider applying for temporary insurance so that, at least, you have major medical protection. Short term plans are subject to medical underwriting, however, the list of health conditions that you could be denied for is usually a lot shorter. This means you are more likely to get approved. A temporary policy gives you catastrophic coverage for a limited period of time, from one month up to six months. Oftentimes, the policy will cover hospitalization, but not services that relate to a pre-existing condition. Also, it won’t cover preventive care services or prescriptions. For free information, contact an HCC Medical Insurance Benefits Specialist at 1-800-514-0958.
Reapply. If your application for private medical coverage was denied, it might be a good idea to reapply later and possibly get approved. For Kaiser Permanente, applicants may apply again after a minimum number of months. Reapplication doesn’t suggest that you keep reapplying to wear out the underwriters. The idea is to show any progress that you’ve made with respects to your health status. A good example of when reapplication would be helpful is if the application was denied due to obesity. If you lose considerable weight, consider applying again.
Appeal. Sometimes, an underwriter may deny an application because they are unaware of extenuating circumstances. For example, when a pregnant woman applies for insurance after she’s already expectant, she’s likely to be denied coverage because pregnancy is considered a pre-existing condition. One of the ways the underwriter determines if a woman is pregnant is through the last menstrual cycle date. If you are denied coverage because you haven’t had a cycle for months, but it was because you just had a baby, then, request reconsideration. To appeal, follow the instructions from the carrier. Often, the appeal process is outlined in the denial letter.
Network. Talk to friends and family members. Check out blogs like this one. Sharing your story or listening to others could lead you to an alternative that hadn’t presented itself before.


Comment from Thomas Cazneau
Time: August 5, 2011, 10:32 pm

I can relate to his story. I cannot currently be insured by Kaiser without an employer-sponsored plan. I still do support Kaiser Permanente, but it would be nice to know that I can be covered by them even if I lost my job, God forbid.

There are programs for those who have been Kaiser members who cannot qualify on their own Individual Plan. But these can be very expensive. Part of me wants to start a side business just so that I can qualify for a Kaiser Small Business plan, which would be less expensive than some of the other Kaiser programs and even other outside carrier individual plans. I wouldn’t feel comfortable just going to Blue Cross or having a PPO plan because then I would have to see doctors who wouldn’t be as familiar with my health history.

Comment from Holly
Time: August 12, 2011, 11:43 pm

I also depend on group insurance to get coverage. I am super grateful the my group is through Kaiser and not another carrier. Even though I understand that the insurers have to have some guidelines it can be very frustrating. They good news is that Individual Plans and Group Plans are not the only options. They are just the most heard of options.

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