You asked why a health insurance company can refuse to insure a person with a pre-existing condition.

SUMMARY

Health insurance companies consider an applicant’s medical history when deciding whether to insure a person under a policy written on an individual basis. As a result, an insurer may deny coverage under an individual insurance policy to a person with a pre-existing condition. If an insurer does insure the person, it may include a pre-existing condition provision in the policy that excludes coverage for no more than 12 months from the policy’s effective date. The state’s high-risk pool is available to individuals who are unable to obtain insurance in the commercial market because of a pre-existing condition.

The 1996 federal Health Insurance Portability and Accountability Act (HIPAA) limits an insurer’s use of pre-existing condition exclusions. OLR Report 2003-R-0778 provides a complete discussion of HIPAA and state pre-existing condition requirements (copy attached).

PRE-EXISTING CONDITION EXCLUSION

If an insurer agrees to insure a person with a pre-existing medical condition, the insurer may impose a pre-existing condition exclusion in the individual health insurance policy. But the insurer cannot exclude coverage for the condition beyond 12 months following the policy’s effective date. Any pre-existing condition provision in an individual insurance policy may only relate to conditions, whether physical or mental, that manifested themselves or for which medical advice, diagnosis, care, or treatment was recommended or received during the 12 months immediately preceding the policy’s effective date (CGS § 38a-476(b)(2)).

In addition, any pre-existing condition exclusion period must be reduced by any period of “creditable coverage. ” Creditable coverage is the time the insured was covered by a prior health plan, so long as there was not a significant gap in coverage (i. e. , the insured was covered at least 120 days prior to the new policy’s effective date) (CGS § 38a-476(c) and (d)).

HIGH-RISK POOL

The Connecticut Health Care Act of 1975 created the Health Reinsurance Association (HRA) to act as a high-risk pool that makes a comprehensive health care plan available to eligible Connecticut residents (CGS § 38a-556). HRA is a non-profit association comprised of all private insurance companies and HMOs that provide health insurance in Connecticut. It guarantees access to health insurance for those individuals who cannot obtain coverage elsewhere because of their pre-existing conditions. Such high-risk pool coverage often costs more than standard insurance coverage. State law caps HRA rates at between 125% and 150% of standard insurance rates.

An applicant for an HRA plan must be a Connecticut resident between age 19 and 65. Eligible dependents include the applicant’s spouse and unmarried children under age 19 (23 if a full-time student attending an accredited institution of higher learning) who depend on him for support or live with him in a regular parent-child relationship.

Brochures containing plan descriptions, applications, and rate information are available from HRA’s Web site, http: //www. hract. org, or by calling 1-800-842-0004.

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