When do individual health Insurers have to sell me a policy?

In South Carolina, your ability to buy individual health insurance may depend on your health status. 

• In general, companies that sell individual health insurance in South Carolina are free to turn you down because of your health status and other factors. When applying for individual coverage, you may 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 health insurance due to your health status, you may be eligible for SCHIP coverage.
• Under South Carolina law, newborns and adopted children are automatically covered under the parents’ individual health insurance policy for the first 31 days, if the plan covers dependents. The insurer may require that the parent enroll the child and pay the required premium within the 31 days in order to continue coverage beyond the 31 days.
• If you have a disabled child, that child may remain covered under your individual health insurance policy 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 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. South Carolina does not require health insurers in the individual market to sell standardized policies. Health plans can design different policies and you will have to read and compare them carefully. However, South Carolina does require all health plans to cover certain mandated benefits, such as mammograms and diabetes treatment. Check with the South Carolina Insurance Department for more information about mandated benefits.

What about coverage for my pre-existing condition?

• Individual health insurers can impose elimination riders. This is an amendment to your health insurance policy that permanently excludes coverage for a health condition or even an entire body part or system.

• South Carolina insurers can also impose a pre-existing condition exclusion period. The definition of pre-existing condition varies by type of individual health insurance you purchase.
• HMOs can count as pre-existing any condition for which medical advice, treatment or diagnosis was actually received or recommended during the 12-month period immediately before you enrolled. This is called the objective standard. Pre-existing condition periods in HMO individual health plans can be no longer than 12 months.
• If you apply for a non-HMO individual health insurance policy, the rules regarding pre-existing conditions depend on the kind of form you complete when you apply for the policy. There are two types of forms that non-HMO insurers can use. One, a comprehensive form, will ask you detailed questions regarding your medical history. The other, a simplified form, will ask minimal questions regarding your medical history. The insurer selling the policy decides which form it will use at the time you apply.

If the insurer uses a comprehensive form, then it can refuse to cover any condition that you disclose for the first 24 months, or it can impose an elimination rider, which is an amendment to your health insurance contract that permanently excludes coverage for a health condition, body part, or body system.

In addition, if you make a claim during the first 2 years your policy is in force, the insurer can refuse to pay that claim and others related to the condition if it determines the condition was pre-existing.  Pre-existing conditions include those that were not previously diagnosed, but caused symptoms for which most people would have sought care.   This is called the prudent person rule.

If the individual insurer used a simplified form when you applied for insurance then a different set of rules apply.  Contact the South Carolina Insurance Department for more information.

• In South Carolina, all individual insurers can consider pregnancy a pre-existing condition. Genetic information cannot be considered a pre-existing condition.
• Individual insurers do not have to give credit for your prior coverage, unlike group health plans and SCHIP coverage. However, if you move from one individual market policy to another, you are assured the right to buy another individual policy from the same insurer, provided that the new plan is a policy of equal or lesser benefits.

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

• If you have an expensive health condition, your individual health insurance premiums may be very high. The law does not prohibit South Carolina health insurers from charging you more because of your health status, age, gender, and other case characteristics. The South Carolina Insurance Department does check premiums for reasonableness in general.
• When you renew your individual coverage, your premiums can increase as your age increases.

Can my individual health insurance policy be canceled?

• 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.
• 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 6 months. If you want to renew coverage under a temporary policy after it expires, you will have to reapply and there is no guarantee that coverage will be re-issued at all or at the same price.