Could my application for private health insurance be denied?

With the exception of children under 19, individual health insurance applications can still be denied due to medical reasons. When the Health Reform mandate is fully implemented in 2014, then a person’s health history can no longer be grounds for non-approval for medical coverage.

What if I have pre-existing health conditions?

Not all pre-existing conditions result in non-approval. The underwriter will evaluate each application on a case by case basis. Applicants will be evaluated based on their medical history and may be denied if they have serious health issues. As mentioned earlier, children under 19 are not subject to denial due to medical reasons. For more information, click pre-existing health conditions.

Is there anything I can do to increase my chances of getting approved?

Most of the questions on a health insurance application will ask if you’ve had certain medical conditions within a specified period of time. Take the questions at face value. For example, if you had an abnormal lab test six years ago but the questionnaire only asks about the last five years, you can honestly answer ‘no’. Conversely, be sure to answer ‘yes’, when applicable. Non-disclosure could result in penalties and cancellation of the policy.

If you have any of the health conditions on the medical questionnaire or if you are presently taking three or more medications, you might consider submitting a doctor's letter, a copy of the doctor’s report, or medical records along with your application. The clarification will aid underwriting in processing your application more quickly. It will be especially helpful on borderline conditions. If the underwriters need more information, they will contact you.

What happens if I don’t meet the guidelines?

Your application could be denied if it doesn’t meet the underwriting criteria. In some states, the Underwriting Department could also enroll you on a plan that is different from the one you selected. The alternative plan may be a high deductible option or one that excludes certain benefits, such as prescription coverage. If you qualify for coverage under HIPAA (“American Health Insurance Portability and Accountability Act of 1996”), get more information by contacting your insurance representative.

Could I reapply?

In some cases, it would be highly recommended that you apply again. For example, if you were denied coverage because you were underweight or overweight but you have since made changes to bring your weight to a level that is appropriate for your height, then apply again. To see how your weight-height comparison fares, click the Kaiser Permanente Body Mass Index Calculator. Some carriers require a minimum of a six month waiting period before they will accept an application for a previously-denied applicant.

How do I cancel coverage?

If you are offered an alternative plan and you do not want that plan, or if you decide not to pursue membership for any reason, you can easily cancel the policy by contacting the carrier. If you cancel the policy during the first 30 days after approval, you will usually not be obligated to pay any premium. Typically, membership is on a month-to-month basis, so you can discontinue coverage at any time. Some insurance companies require advance notice of cancellation, so be sure to check with the carrier.

Typically, membership is on a month-to-month basis, so you can discontinue coverage at any time. Some insurance companies require advance notice of cancellation, so be sure to check with the carrier. If you cancel the policy during the first 30 days after approval and have not utilized the services, it is unlikely that you will be obligated to pay any premium.

Typically, cancellation is effective the first of the next month, or the anniversary date. Premium is not usually pro-rated. Verify the company’s cancellation process with your insurance representative.

What happens if I don’t meet the guidelines?

If your request for private health insurance is not approved due to medical reasons, consider the following:

• If you disagree with the decision of the underwriter, you can submit a request for reconsideration. The notification letter of denial will include detailed instructions on how to file an appeal. Underwriting will not discuss appeals by phone, so be sure to follow the directions on the letter. If you need a duplicate denial letter for a KP application, contact the Kaiser Permanente Member Services Department at 1-800-464-4000 in California and Colorado, or 1-888-865-5813 in Georgia.
• If you are a business owner and there are at least two employees working for the company, you could qualify for health benefits through your company. If you are not a business owner but your employer is open to providing group coverage, you could qualify under an employer-sponsored plan. Look into Kaiser Permanente Group Health Insurance and get a quote.
• You could qualify for state-funded health coverage under the Major Risk Medical Insurance Program. Click MRMIP for additional information.