The federal, state and commercial health insurance exchanges require an applicant to answer questions about medical history when applying for coverage and sometimes even to get pricing (for group coverage).
Sometimes this can be challenging, especially when it is difficult to understand
the meaning or the intent of the questions. This article is meant to offer
General advice on answering medical questions on an insurance application:
1. The response on the insurance application must be your
own (or a legal guardian, if applicable). No other person is legally authorized to
provide the responses on an insurance application. If
another person answers the application questions, you are
still legally responsible in the same manner as if you had
answered the questions yourself. Insurance company personnel,
agents, brokers and insurance advisers are specifically
prohibited from answering these questions. Professionals in
the medical field and human resource departments should
avoid providing answers to insurance application questions
as a matter of professional standards and liability
management but they are not legally prohibited from doing so
under state or federal law.
2. It is not necessary to obtain and review a copy
of your personal medical records from all of your medical
providers, however, it might be smart to do so. The medical
records may be quite different from our understanding or
recall of the diagnosis and treatment due to a number of factors
including memory and recall issues, imprecise medical
terminology used in verbal discussions with providers and
perhaps a tendency for medical providers to attempt to
maximize the patient’s positive mental state during
treatment by minimizing the discussion of adverse medical
findings. We frequently find that basic key words like
“diabetes” and “cancer” are not interpreted by the patient
in the same way as recorded in the medical records.
Remember that in the event of a difference between a written
detail in a medical record and a non-written detail, the
written record will always prevail.
3. You are under a
legal requirement of the laws of your state to answer the
insurance application questions honestly and to the best of
4. Don't lose sleep over an unintentional error. There is
no legal requirement that you
answer the insurance applications with 100% error-free
accuracy and completeness. Health reform laws are
specifically intended to protect those who make an
unintentional error on an insurance application.
Consumer-protection laws overwhelmingly side with the
consumer unless there is clear intention of fraud.
Insurance company possible
5. In the event that there is overwhelming
evidence that an insurance applicant deliberately questions
falsely, the insurance company can cancel or rescind the
insurance for fraud.
This action is severely limited by the Affordable Care Act of
6. In the event that an inadvertent error
was made in answering the questions, the insurer may not
cancel or rescind coverage but may deny specific coverage
or a claim based on the facts. For example, a claim in the
first month of the policy may be denied on
the basis that a pre-existing condition was not disclosed on
the application and the policy has a 6 month waiting period
for pre-existing conditions.
7. Pre-existing medical conditions trigger two
questions that must be addressed independently:
a. Does my
pre-existing condition allow me to qualify for enrollment in
a specific insurance?
b. If enrolled, how will my pre-existing condition be
Each of these questions must be addressed separately and
additional suggestions follow below.
8. The definition of
pre-existing condition varies from state-to-state and may
not apply to medical conditions that occurred in the distant past.
It might not be as encompassing as you suspect. If in doubt, ask OnlineAdviser for the state-specific
definition of pre-existing condition.
9. The intention of federal and state health
reform law is to make individuals eligible for insurance
regardless of health history (not be declined for
The trade-off is that guaranteed issue coverage might only
be offered at certain open enrollment periods each year and
not on a permanent ongoing basis.
10. Health reform laws do not
completely eliminate restrictions on coverage, waiting periods or
exclusions for pre-existing conditions when there has been a
significant gap in coverage.
11. Short term major medical
insurance does not cover the cost of treating pre-existing
medical conditions and is exempt from the reform laws that would
12. Everyone, regardless of medical history, is eligible for
at least one
health insurance plan. Federal health reform law
set up new health plans for those with pre-existing
conditions who were not able to find coverage for an
extended period of time.
13. Employer-sponsored health plans accept
all eligible employees regardless of medical history during
periods of open enrollment.
Waiting periods of up to 90 days for eligibility still apply to
most employer-provided health plans. Employers are permitted
to charge employees different rates for insurance based on
their participation and results of health improvement plans
but not based solely on their answers to medical questions.
14. Some individual insurance plans will continue to be
available only to preferred risk applicants
who answer a number of medical questions
even after full implementation of federal health reform
15. Don’t fight with the
insurance application. Avoid “over-thinking” the issue.
Don't provide more information than is requested. Answer
simply with the response that strikes you as most
appropriate when applying common sense.