What is the Eligibility Criterion for Health Care Insurance?

Although each insurance company has its own underwriting rules, all companies take into account the basic factors that affect how much it will cost to offer health insurance coverage. Some insurers have stricter underwriting standards than others, but most companies automatically deny the application if they engage in predetermined high risk behaviors or suffer from certain preexisting health conditions.

Medical History

An insurance company may deny health coverage if you have a history of a medical condition such as cancer, cardiovascular disease, diabetes, rheumatoid arthritis, lupus, Parkinson’s disease, or polycystic kidney disease. The insurers consider applicants with these and other chronic or recurrent diseases not insurable because of the high cost of the treatment. The applicants who have a medical history of asthma, high cholesterol, hypertension, osteoporosis, ulcers, and thyroid dysfunction may be accepted by a health plan, but are usually charged a higher premium rate or less coverage offered. An insurer typically requests to review the applicant’s medical records and recent laboratory reports when deciding whether to accept or reject the application. Determining factors generally include the severity of a medical condition, how well the disease is controlled with medications, and how long it has been since diagnosis or the last active episode of the Disease Health

Body Mass Index

As a general rule, insurance companies include the height of weight standards and their underwriting standards when rating the health risks of the applicant. The insurers often associate excess weight with an increased risk of premature death. If you are overweight or obese with a body mass index above 39, most companies will refuse your application for coverage. A BMI between 30 and 39 can get you approved but with a higher premium. An insurance company may reject your application even if your BMI is below 30 or if you have diabetes or heart disease related to a weight problem.

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Life Habits

Along with your age and employment history, an insurance application usually asks you if you smoke, drink alcohol, or use recreational drugs. Fines, DUI arrests or abusing prescription drugs are other risk factors that can lead to an insurance company being able to deny your health insurance application. Omitting or falsifying any of the facts could give rise to a claim that was denied later if the company approves your request. An insurer can simply state that not all of the facts were known at the time you filed your claim. Otherwise, you have not been approved or are enrolled in the health plan.

Risk Behaviors

The insurance companies consider whether an applicant engages in risky behavior, either as part of employment or as a hobby. There are certain occupations that may disqualify for individual health insurance coverage or at least have a high premium cost. Fire extinguishing, commercial fishing, mining, law enforcement and forestry are some of the high-risk occupations that may be classified as uninsurable. Working with explosives, asbestos or other hazardous materials can also get your application denied. Participating in dangerous hobbies can also significantly increase health insurance premiums. The hobbies that insurance companies give cause for concern include parachuting, rafting, scuba diving, rock climbing, flying a light aircraft, snowboarding and skiing.