insurance denials and pre-existing conditions

Not anymore. Thanks to the Affordable Care Act, since 2010, insurance companies are no longer able to deny coverage or raise premiums for individuals with pre-existing conditions.

Insurance companies typically assess applications through underwriting, where they evaluate the risk associated with insuring certain individuals, looking at medical history, age, occupation, lifestyle and any pre-existing conditions. Before, some people deemed “high-risk” could face coverage denials, dollar limits on coverage or experience unreasonable delays in receiving claim approval. The Affordable Care Act was intended to ensure there were contingencies in place so everyone who wanted coverage could get it, regardless of how bad their health was, how expensive their conditions were to treat and their income.

That said, not every plan is available on ACA exchanges, and some may not comply with every requirement of ACA rules. Examples include short-term health insurance plans, healthcare sharing ministries and association health plans, which aren’t required to adhere to the same consumer protections. There are also less expensive accident-only or critical illness insurance plans that don’t meet the ACA criteria but may be preferable to healthy people with no pre-existing conditions.

 

What Qualifies as a Pre-Existing Condition?

A pre-existing condition is any condition that was present before you enrolled in a health insurance plan or renewed your policy. If you have been diagnosed with or treated for a particular issue before applying for health insurance, it could be considered a pre-existing condition.

Examples of pre-existing conditions include:

  • Chronic diseases (hypertension, heart disease, chronic obstructive pulmonary disease (COPD))
  • Mental health disorders (depression, anxiety, PTSD)
  • Autoimmune diseases (rheumatoid arthritis, multiple sclerosis (MS), Crohn’s disease)
  • Infectious diseases (HIV/AIDS, hepatitis C, tuberculosis (TB), Lyme disease, human papillomavirus (HPV))
  • Genetic conditions (cystic fibrosis, Huntington’s disease, sickle cell anemia, hemophilia)
  • Cancers
  • Asthma
  • Obesity
  • Substance Abuse Disorders
  • Sleep Apnea
  • Previous Surgeries or Injuries

 

Were Women Charged More for Insurance in the Past Than Men?

Yes. Historically, before the Affordable Care Act, insurance companies were legally allowed to charge women more for insurance than men of the same age and with the same amount of coverage. Insurance companies would classify pregnancy, miscarriage and infertility – to name a few – as pre-existing conditions. In some cases, a woman’s rate during her child-birthing years could be up to double her male counterpart’s rate.

Today, the pre-existing condition clause of the act has reduced this gender-based discrepancy. However, even after these new healthcare laws were enacted, healthcare plans that exist outside the ACA purview can still occasionally subject female enrollees to higher premiums.

 

The Affordable Care Act’s Shortcomings

With enhanced coverage and lower premiums for low-income individuals and families come some drawbacks. Insurance costs have gone up for those who don’t qualify for credits or reduced-cost plans. The increased costs of enhanced coverage have, in some ways, been passed on to consumers in part through higher deductibles and premiums. ACA plans have also cut costs by limiting the breadth of networks, meaning consumers who have ACA plans may have fewer local in-network healthcare providers to choose from, leading to longer wait times for care.

There are also some complications for businesses and employees. Technically, small businesses with 50 or more full-time employees must provide health insurance. Some businesses have responded by hiring fewer employees or cutting hours so they don’t have to comply, which isn’t ideal for affected workers who get fewer hours and employer-provided coverage.

 

What Should I Do If I’ve Been Unfairly Denied Coverage?

If you believe you’ve been denied coverage or care in violation of the ACA, the dedicated referral counselors at Minnesota Lawyer Referral and Information Service can connect you with a qualified attorney. We have an exclusive network of over 200 private practice Minneapolis–St. Paul attorneys, including many with experience handling insurance disputes.

 

Get Help Finding an Insurance Attorney You Can Trust to Expertly Represent Your Case in Minnesota

At Minnesota Lawyer Referral and Information Service (MNLRIS), we rigorously vet the attorneys in our vast network to ensure we only schedule appointments with lawyers who have the relevant expertise and experience.

You can learn more by exploring our healthcare laws FAQs or call (612) 752-6699 to get in touch with a private practice insurance lawyer who will fight for your ideal case outcome today.