Consumers: Individual Health Insurance Underwriting/AB 356
Consumers: Individual Health Insurance Underwriting/AB 356
California Department of Insurance
Individual health insurance is insurance you buy on your own, rather than having it provided by your employer. Please examine your options carefully before declining group coverage or continuation coverage, such as COBRA, that may be available to you. You should be aware that companies selling individual health insurance typically require a review of your medical history that could result in a higher premium or you could be denied coverage entirely.
If you are in the market for individual health insurance, most insurance companies have online tools to help you find out how much individual health insurance will cost. If you have a chronic illness or other health condition, it can be hard to buy individual health insurance. If you have applied for individual health insurance and been denied, the information below may help you determine why you may have been denied and if that denial was appropriate.
Underwriting
When you apply for individual health insurance, the health insurance company uses a process called underwriting to look at your age, sex, and health history to decide whether it will cover you and how much it will cost to provide you coverage.
Do all health insurance companies have the same underwriting guidelines for offering insurance?
No. Each insurance company has its own underwriting guidelines, which are usually not made public. However, insurance companies marketing and selling individual health insurance policies in California must file information with the Department of Insurance pertaining to their policies, procedures and underwriting guidelines for offering such insurance (Insurance Code Section 10113.95 which was added by Assembly Bill 356 in 2005). We have summarized the information that companies have filed in the questions and answers and chart below.
Health conditions that would automatically not be approved;
Health conditions that may not be approved;
Height and weight standards;
Health history, health care service utilization, and lifestyle or behavior that may cause the insurance company to deny insurance, limit the products they offer, or charge more for the coverage.
What health conditions will cause a health insurance company to automatically refuse or deny my application for insurance?
There are many medical conditions that may cause an insurance company to automatically deny or not approve your application. These may include the following:
Health problems for which you have not seen a doctor;
Health problems that a doctor cannot explain;
Health problems for which you have not completed treatment.
An insurance company may also automatically deny your application for the health conditions below. There may be other health conditions that are not on this list.
AIDS;
Pregnancy, pregnancy of your spouse or significant other, planned surrogacy or adoption in process;
Cancer, under treatment;
Sleep Apnea;
Severe mental disorders, such as major depression, bipolar disorder, schizophrenia or psychopathic personalities;
Heart disease;
Renal failure or Kidney Dialysis;
Diabetes with complications;
Cirrhosis;
Multiple Sclerosis;
Muscular Dystrophy;
Systemic Lupus Erythematous;
History of transplant;
Lymphedema;
Current infertility treatment;
Hepatitis;
Hemochromatosis.
What will cause an insurance company to offer me insurance at a higher premium rate or limit the products or benefits I can get?
Insurance companies may offer you insurance at a higher premium and/or limit the products or benefits you can purchase if you had a health problem in the past but you have recovered or you have been without symptoms for some time. Insurance companies will also do this for minor health problems that you had in the past or may currently have. Insurance companies argue that these conditions pose a risk that it will cost more for your health claims than if you were completely healthy. Each application and insurance company is different. An insurance company may charge a higher premium or limit the products offered for the health conditions below. There may be other health conditions and time frames that are not on this list.
Stroke, after 10 years with no reoccurring problems;
Allergies, while testing is in process;
Ear infections, controlled with medications;
Lyme's disease, without symptoms after one year;
Breast Implants (non-silicone);
Ringworm;
Joint sprain or strain, recovered and no restrictions;
Migraine headache, mild and infrequent with no emergency room visits;
Mild depression.
Will a health insurance company look at my height and weight when I apply for insurance?
Yes. Insurance companies usually look at your height and weight when they decide to offer insurance. They may offer you insurance at a higher premium rate or refuse to insure you if you are overweight or obese. Some insurance companies use a measurement called the Body Mass Index (BMI) to decide. If your BMI is above 39, most insurance companies will not offer you insurance. If your BMI is 30-39, an insurance company may offer you insurance at a higher premium. If you have health problems because of your weight, such as diabetes or heart disease, an insurance company may refuse to insure you, even if your BMI is under 30.
Can a health insurance company look at my smoking and drinking history when I apply for insurance?
Yes. Insurance companies may look at smoking and drinking history when they decide whether to offer insurance.
The following chart summarizes underwriting information that health insurance companies have filed with the Department of Insurance.
AB 356: Summary of Underwriting Information filed re conditions for which no insurance coverage will be offered, application will be denied, or higher premium may be charged or benefit may be limited
Condition Insurance Company Action
Health problems for which you have not seen a doctor Automatic decline for some companies
Health problems that a doctor can not explain
Automatic decline for some companies
Health problems for which you have not completed treatment
Automatic decline for some companies
AIDS
Automatic decline
Pregnancy, pregnancy of your spouse or significant other, planned surrogacy or adoption in process
Automatic decline
Cancer, under treatment
Automatic decline
Sleep Apnea
Automatic decline or higher premium will be charged
Severe mental disorders, such as major depression, bipolar disorder, schizophrenia or psychopathic personalities
Automatic decline
Heart disease
Automatic decline
Renal failure or Kidney Dialysis
Automatic decline
Diabetes with complications
Automatic decline
Cirrhosis
Automatic decline
Multiple Sclerosis
Automatic decline
Muscular Dystrophy
Automatic decline
Systemic Lupus Erythematous
Automatic decline
History of transplant
Automatic decline
Lymphedema
Automatic decline or higher premium will be charged
Current infertility treatment
Automatic decline
Hepatitis
Automatic decline
Hemochromatosis
Automatic decline
Rheumatoid Arthritis
Automatic decline
Stroke, after 10 years with no reoccurring problems
Automatic decline or higher premium will be charged
Allergies, while testing is in process
Automatic decline or higher premium will be charged
Ear infections, controlled with medication
Higher premium may be charged
Lyme's disease, without symptoms after one year
Automatic decline or higher premium will be charged
Breast Implants (non-silicone)
Automatic decline or higher premium will be charged
Ringworm
Higher premium may be charged
Joint sprain or strain, recovered and no restrictions
Higher premium may be charged
Migraine headache, mild and infrequent with no emergency room visits
Higher premium may be charged
Mild depression
Automatic decline or higher premium may be charged
Obesity
Automatic decline or higher premium may be charged
STD (Sexually Transmitted Disease)
Automatic decline or higher premium may be charged
Contact Us
Consumer Services Division
The Consumer Services Division (CSD) is a member of the Consumer Services and Market Conduct Branch of the California Department of Insurance (CDI). CSD is responsible for gathering and responding to consumer inquiries regarding insurance company or producer activities. CSD maintains three separate bureaus to handle telephone inquiries (Consumer Communications Bureau), as well as, respond to consumer complaints in regards to claims handling practices (Claims Services Bureau) and/or rating and underwriting issues (Rating and Underwriting Services Bureau).
California Department of Insurance
Consumer Services Division
300 South Spring Street, South Tower
Los Angeles, CA 90013
Fraud Division
Information concerning suspected insurance fraud should be directed to the addresses below. Click here for further information regarding the types of fraud investigated by the Fraud Division.
California Department of Insurance
Fraud Division
9342 Tech Center Drive, Suite 100
Sacramento, CA 95826
fraud@insurance.ca.gov
A list of regional offices is available.
Producer Licensing Bureau
The Producer Licensing Bureau is assigned the mission to protect the public from economic loss caused by misrepresentation, dishonesty and incompetence by determining the qualifications and eligibility of applicants for licenses; maintaining and updating records of all licenses issued including information regarding licensee continuing education status; and approves prelicensing and continuing education providers and courses. Matters regarding insurance licensing and education should be directed to:
California Department of Insurance
Producer Licensing Bureau
320 Capitol Mall
Sacramento, CA 95814
800-967-9331 or
916-322-3555
E-mail Inquiry
Legal Unit
Companies wishing to do business in California, existing companies seeking approval of new products, and those requesting information related to the Public Records Act should direct correspondence to the Legal Division. The Legal Division does not provide legal representation to individual citizens about insurance related matters. If you have questions about consumer protection law, the California insurance code, or other questions involving the legal, judicial, regulatory process that our Department utilizes, please contact:
California Department of Insurance
Legal Division
45 Fremont Street
San Francisco, CA 94105
Email to the Custodian of Public Records
Office of the Ombudsman
Beyond helping to ensure prompt responses and exemplary customer service, the Office of the Ombudsman engages in activities aimed at providing additional information to consumers. This office highlights critical insurance issues, focuses the spotlight on areas in need of regulatory reform, and facilitates a healthy exchange between consumers and the CDI. Individuals seeking a review of how the Department has handled their concern should contact:
California Department of Insurance
Ombudsman's Office
300 Capitol Mall, Suite 1600
Sacramento, CA 95814
Ombudsman@insurance.ca.gov
2008 California Department of Insurance
