The main point of underwriting is to determine whether or not an individual is worth selling a health insurance plan to, or if they are too expensive to cover. Each company has its own guidelines for medical conditions they automatically decline, and others they decline based on age in conjunction with the illness. Some applicants who qualify as having some kind of condition can be a certain age and receive an elevated premium instead of a complete decline. It all depends on the risk criteria laid out by the carrier’s underwriting guidelines
To demonstrate what a typical list of declinable conditions looks like, we have included a page from the underwriting guidelines of a national health insurer. Whether you are an agent or a consumer wondering what conditions can be turned down for health insurance, this is a good example of what that list looks like in many cases. Of course, variables make no list a definite and each set of underwriting guidelines unique. Every plan in every state from every company has its own specific list of conditions, rewritten every year to stay current.
Medications are another large area of concern for insurance companies when considering an applicant. As many prescriptions are expensive and treat serious mental and physical illnesses, the presence of one or more medications on an insurer’s list is a big “no.” Prior knowledge that they will be expected to pick up the tab for a medication that is known for being too costly requires insurers to automatically decline certain applicants.
If the medication is on their list of declinable prescriptions, an applicant will be dismissed without any further questions or information needed. However, dependents under the age of 19 can receive coverage despite taking medications on this list, and will be assigned to the appropriate risk category.
Conditions Needing Additional Information
Other conditions require additional information before determining if the applicant is a total decline or a rate up case. To receive additional information, the insurance company will call the applicant directly for certain conditions to get necessary information, and eliminate the need to request medical records. In most cases, the carrier is able to collect the information needed over the phone, but if they get no response there is a possibility their case will be closed.
If the insurer is unable to contact the applicant or their physician after 3 attempts to obtain additional information, medical records with specific diagnosis and test results surrounding the incident or illness will be needed. (This is specific to the carrier whose underwriting guidelines we are showing) Depending on the test results, how much treatment is needed after diagnosis, or whether the condition has been cured or eliminated, the underwriter will decide on your eligibility. If you have test results that show the need for more treatment, you could be turned down based on the condition.