When Do Individual Health Insurers Have to Sell Me a Policy?

In Louisiana, your ability to buy individual health insurance policy may depend on your health status.

• In general, companies that sell individual health insurance in Louisiana are free to turn you down because of your health status and other factors.  When applying for an individual health insurance policy, you will be asked questions about health conditions you have now or had in the past.  Depending on your health status, insurers might refuse to sell you coverage or offer to sell you a policy that has special limitations on what it covers.
• If you have trouble buying private individual health insurance due to your health stats, you may be eligible for LHP coverage (see page 20).
• Under Louisiana law, newborns and adopted children may be covered under the parents’ health plan.  The insurer may require that the parent enroll the child and pay additional premiums prior to, or at the time of, birth or adoption.
• If you have a disabled child, that child may remain covered under your individual health insurance after he or she reaches the age at which dependent coverage is usually terminated.   To qualify, your adult son or daughter must be incapable of self-support because of mental retardation or physical disability and must be chiefly dependent on the policyholder for support.  Proof of incapacity must be furnished within 31 days of reaching the time limit and may be required periodically thereafter.

What will my individual health insurance policy cover?

• It depends on what you buy.  Louisiana does not require individual health insurers in the individual market to sell standardized policies.  Insurers can design different policies and you will have to read and compare them carefully.  However, Louisiana does require all health plans to cover certain benefits – such as mammograms, and diabetes training program for self-management.  Check with the Louisiana Department of Insurance for more information about mandated benefits.

What about coverage for my pre-existing condition?

• Individual health insurers can impose pre-existing condition exclusions periods.  Typically, pre-existing condition exclusion periods cannot exceed 12 months.  However, insurers are permitted to impose pre-existing condition exclusion periods exceeding 12 months, including elimination riders, on up to 2 specified medical conditions.  An elimination rider is an amendment to your health insurance policy that permanently excludes coverage for a health condition.
• The definition of pre-existing condition is different under individual health insurance than under group health plans.  Individual health policies can count as pre-existing any condition for which you received, or – in your insurer’s judgment, for which you should have sought – a diagnosis or medical advice or treatment in the 12-month period prior to obtaining the individual health policy.  This is called the prudent person rule.  Insurers are also permitted to use the objective standard to determine pre-existing condition periods.  Individual health policies can apply pre-existing condition exclusion periods for pregnancy, but not for genetic information.
• If you make a claim during the first three years of coverage, the insurer can look back 12 months from the time of your application to see if the claim is for a condition that would have been considered a pre-existing condition.  If the insurer determines that the condition is a pre-existing condition, it can refuse to pay for expenses for that condition.
• In Louisiana, pregnancy can be considered a pre-existing condition in individual health insurance policies, but genetic information cannot.
• Individual health insurers are required to give you credit toward 12 month pre-existing condition exclusion periods for any prior continuous coverage that was not interrupted by a break of 63 or more days in a row.  Insurers are not required to give credit for prior coverage for pre-existing condition exclusion periods exceeding 12 months or elimination riders.

What can I be charged for my individual health insurance policy?

• In Louisiana, there are limits on how much individual health insurance premiums can vary due to health status, age, gender, and other factors.  Even within these limits, however, if you have a serious health condition, your premium may be significantly higher than the rate charged for other individuals.  In addition, when you renew your individual coverage, premiums can increase substantially as you age.
• If you have questions about your premiums, contact the Louisiana Department of Insurance.

Can my individual health insurance policy be cancelled?

• Your coverage cannot be canceled because you get sick. This is called guaranteed renewability. You have this protection provided that you pay the premiums, do not defraud the company, and, in the case of managed care plans, continue to live in the plan service area.
• Your health insurance policy may be canceled if the insurer discontinues your health policy or withdraws from the individual market. Upon meeting other requirements, you may be guaranteed an individual policy from the Louisiana Health Plan.
• Some insurance companies sell temporary health insurance policies. Temporary policies are not guaranteed renewable. They will only cover you for a limited time, such as six months. If you want to renew coverage under a temporary policy after it expires, you will have to reapply for a new contract. There is no guarantee that coverage will be re-issued at all or at the same price.