Can You Buy Affordable Individual Health Insurance If You're Sick or Pregnant?

"I'm trying to get an individual policy. I've put off buying a policy because they cost so much. But now I'm pregnant (or I've been diagnosed with an expensive illness) and I need health insurance. I've applied to several insurance companies, but they turn me down. What can I do now?"

This is one of the biggest problems with America's present system for financing health care. - it's hard to get insurance if you really need it.

If you aren't eligible for insurance through your employer, you will need to purchase an individual policy. Applications for privately purchased health insurance policies are carefully checked to see if you will be profitable for the health insurance company. They'll contact your doctors and get medical records, and look them over with a fine toothed comb. It is very possible that your pregnancy (or diabetes, heart problems, or even prior automobile accidents) will flag the underwriters to turn you down.

Some insurance companies will even turn down the father of an expected baby, if the couple is married - this makes sure the child will not be automatically eligible for coverage when it's born. A baby born with health issues could pile up thousands of dollars in medical bills, and this makes insurance companies nervous.

Even if you're offered an individual plan, there may be a one-year waiting period before any pregnancy-related costs or pre-existing conditions would be covered. Be sure to read the fine-print of your contract, if you are offered one. A pre-existing condition is usually considered to be any illness or condition for which you have been treated in the past six to 12 months, or any condition for which a prudent person would seek treatment. If you think you're sick but you haven't yet seen the doctor, you may still find your claims denied if the insurance company feels that you should have known about your illness before you applied for coverage.

Since you don't have time to lobby your congressperson to fix the health care system and create universal health care, you need some quick solutions if you're already sick or pregnant. There may be options for you - but they aren't perfect, and they may not be cheap.

If you have a low income you may be eligible for your state's health plan or Medicaid. Many states are now financially strapped, just as you are, so they have very stringent eligibility requirements, and there is probably a waiting list. Be sure to check with your state's program to find out if you qualify.

If your income is too high to qualify for a state-sponsored plan, you may be eligible for your state's high risk insurance pool. You do pay premiums for these plans, and the premiums may be fairly high. Basically, these plans group together the high-risk individuals in the state, which allows each individual the coverage that they can't get through a private insurance plan.

To qualify for one of these high-risk plans you may need to show that you have been turned down by a private company, or an agent may be able to certify that you are likely to be turned down.

Unfortunately, your state's high risk pool insurance may also deny claims for pre-existing conditions, including pregnancy, for six months or more. If this is the only policy you will be eligible for and you're already pregnant, apply as early as you possibly can so that your delivery and nursery room charges will be covered. If you have been diagnosed with an expensive illness, such as cancer, you may need to pay all medical expenses yourself until the pre-existing condition exclusion period is over.

When I worked for a health insurance company, I always advised callers to seek the advice of an insurance agent if they felt they might not qualify for our individual policies. Agents are paid their commission by the insurance companies, so their services don't cost the customer extra money. Agents also have a very good idea if the customer's medical condition will disqualify them from coverage, and they'll be aware of the policies of all health insurance companies in the state. This means that they'll be able to steer you to the state's high risk insurance pool right away, instead of waiting for you to apply to the private insurance company and being denied coverage. If the state's policy has a six month waiting period, and you already know you're pregnant, the extra month it takes to get an answer from a private insurer could put your delivery date past the high risk pool's exclusionary period. The agent's knowledge could save you thousands of dollars in denied claims.

The best advice (although it's difficult to follow with today's high health insurance premiums) is to get a policy long before you ever get pregnant or sick. Or be employed by a company that offers group coverage. You may find that it pays to accept a lower wage in order to be eligible for a group policy without a pre-existing condition waiting period, but before you accept a job for this reason alone, check the fine print. In some states, even group policies can deny claims for pre-existing conditions, such as pregnancy, for a specified period of time.