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This Web site contains a compilation of more than a thousand consumer finance  columns written by Tony Novak from the 1980s through 2006, updated and reformatted for maximum usefulness today.  New material was added after 2010.

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Qualifying for health insurance

originally posted: 11/22/2006  reposted: 2/18/2011 This post has not been recently reviewed or revised by the author and may be out of date. If in doubt, please send a new question or ask for an update.

Q: I was reading the medical eligibility questions for one of the short-term health policies you advocate and I have a problem with one condition. If one has a cancer or tumor within five years one is disqualified. I had a small growth removed three years ago called a lipoma. It is a small fatty deposit which could be classified as a tumor. Is there any way to find-out from the insurer?

A: Your question raises important points that apply to all health insurance. First, an insurance company does not make a pre-determination of your eligibility for coverage. The same applies to agents, advisers, and HP department personnel. You must rely solely on your own judgment. Second, the insurance is issued or not issued solely based on your responses to the questions on the application. In this case, if the questions are answered "no" the insurance is issued. If any of the questions are answered "Yes" insurance is not issued. (Note that applications are never "declined" by the insurance company since you determine eligibility yourself). Third, once insurance is issued, it can be rescinded (the legal term for reversing the issuance of insurance) only based on material or intentional misstatement. The insurance company must take the position that you knew or should have known that you did not qualify for insurance. This process favors the consumer in "grey area" issues since the policyholder usually has more information and can present a logical reason to support the answer given on the insurance application. In your case it seems clear that if you had a tumor then you do not qualify for most types of health insurance. It is unclear whether the medical condition you had is a tumor. You are the only person who has the medical history detail necessary to build a logical opinion as to whether this was or was not a tumor. If you are unclear, you may wish to consult your medical records or ask your doctor point-blank "Was the condition I had a "tumor"?" The most common mistake that consumers make in this area is to say, for example, "my doctor says I do not have a tumor but I am worried that the insurer will consider this a tumor and cancel my coverage." This mistaken thinking misses the core point of the law on this matter. On the other hand, if your written medical records contain the word "tumor" in you diagnosis then there should not be any need for further discussion. In this case, you do not qualify. As an side issue, we strongly recommend that every person should have a copy of their entire medical history records in their possession for a variety of reasons, this situation being just one of those reasons.


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