Pregnancy is no longer considered a pre-existing condition for health insurance purposes because of the Affordable Care Act. Previously, health insurance companies could, at their discretion, consider pregnancy a pre-existing condition. The company could then deny health insurance coverage for a pregnancy to a woman who was already pregnant when she became an insured person under a policy.
In fact, before enacting the Affordable Care Act, insurance companies could turn a woman down for health insurance coverage if she applied while pregnant.
Insurance companies could also charge women higher rates for their health insurance coverage if they are pregnant. Again, this kind of discrimination is no longer possible because of the Affordable Care Act. Healthcare companies under the Affordable Care Act cannot deny a woman coverage because she is pregnant and cannot charge a woman more for health insurance because she is pregnant.
Generally speaking, a health insurance company cannot charge a person a higher premium based on a person’s gender or health condition. A premium is an amount a person pays, usually monthly, for insurance.
Still, another option is to file a claim with the federal Office for Civil Rights (OCR) of the U.S. Department of Health and Human Services. A person must file a complaint within 180 days of the discriminatory act. If a person believes they have been denied insurance, coverage for a claim, or otherwise discriminated against based on gender or pregnancy status, they may want to pursue this avenue for relief. A complaint can be filed in writing via the mail, fax, e-mail, or online through the OCR complaint file at www.hhs.gov/civil-rights
How Can I Get Insurance If I Am Pregnant?
First, a person wants to learn whether their employer or partner’s employer offers health insurance to employees and their families. A person is most likely to get the best coverage at the lowest price through the health plan offered by an employer. In part, that is because employees pay part of the cost of insurance premiums with employers.
If an employer plan is unavailable, a person can shop for health insurance coverage in the exchange. In the marketplace, a person can:
- Compare health plans side by side;
- See if their income is in the range to qualify them for financial help from the government to pay for the insurance. This could lower the cost of a person’s insurance premiums; they might also find that they qualify for lower out-of-pocket costs, such as lower deductibles, copays, and coinsurance.
A person has to enroll in a health plan during the open enrollment period, set by either the employer for the employer’s insurance coverage or the federal government for Marketplace coverage.
A person may qualify for a special open enrollment period if they have a “life event” such as losing other health insurance coverage or moving to a new state. Unfortunately, pregnancy is not one of the life events which qualify a person for a special open enrollment period. But having a baby or adopting a child is a life event. So if a person does not have insurance and misses open enrollment, once they give birth, they can shop for insurance and enroll in a plan even if they missed the open enrollment period.
If a person’s income is low enough to qualify for Medicaid, a person can enroll in Medicaid at any time during the year and not only during open enrollment. Medicaid provides free or low-cost medical benefits to those who are eligible as follows:
- Adults with a low income;
- Children;
- Women who are pregnant;
- People who are age 65 or over;
- People with disabilities.
A person will check with their state’s Medicaid office to see if they qualify for Medicaid. Generally, a person’s eligibility is determined by several factors, such as:
- Their age;
- Income level;
- Number of family members;
- Whether the person is pregnant or has a disability;
There are two ways to apply for Medicaid as follows:
- They can apply to the state Medicaid agency in the state in which they live:
- They can fill out an application through the Health Insurance Marketplace.
The website to go to is https://www.healthcare.gov.
What Can I Do If I Have Been Denied Coverage Because I Am Pregnant?
There are many ways to appeal insurance decisions. The first step would be to appeal a negative decision within the insurance company. It is possible there was an administrative error that led to the denial.
Each insurance company has its own procedure for appeals, and a person would want to contact the company and ask for information about its appeal process. A person may find it useful to be represented by an attorney at this stage.
If the insurance company continues to deny coverage, it is possible to appeal through the Marketplace. This would involve the federal government agency that reviews how decisions to provide insurance are made and how rates are set.
There are also several levels for submitting administrative appeals within the Marketplace. It is important to exhaust all of them to ensure the insurance company is following the law. A person can find more information at www.healthcare.gov.
Can I File a Claim for Insurance Bad Faith?
Finally, a person can file a civil lawsuit for insurance bad faith. Insurance bad faith is a person’s claim if their insurance company fails to pay their legitimate claim for coverage of a loss. Or, if an insurance company fails to process a policyholder’s claim within a reasonable period, this can also constitute insurance bad faith.
State courts have held that every insurance contract has an implied covenant of good faith and fair dealing. If an insurance company does not perform as required by the terms and provisions in their policy, e.g., by denying a legitimate claim, they have violated this covenant and can be liable for insurance bad faith.
An insurance company also acts in bad faith when they misrepresent the language in an insurance contract to an insured person to avoid paying a claim. An insurance company can also be liable for bad faith if they do not disclose policy limits and exclusions to a potential customer before they buy a policy. Or, a company may make unreasonable demands on the policyholder to prove that they suffered a covered loss.
If a person has experienced any of these issues with an insurance company, they would want to proceed as follows:
- Request an administrative hearing regarding the insurance claim denial with the insurance company. It is important to take this step first because the insurance policy may contain a provision requiring the insured person to “exhaust all available remedies” before filing a civil lawsuit. If a person fails to take this step, it could result in the dismissal of a lawsuit that is filed later;
- If the administrative hearing does not result in an acceptable remedy and the person thinks they still have a legitimate claim, they can file a civil lawsuit against the insurance company seeking coverage for their claim or other relief.
Do I Need the Help of a Lawyer for My Insurance Pregnancy Issue?
If you think you have been denied health care coverage because of pregnancy, or you know someone who has, an insurance lawyer can advise you of your options, such as whether you should file a claim for wrongful denial of coverage or insurance bad faith. Your lawyer can help you make your best case to be sure your right to health care is protected.
