The Impact of Using Health Insurance

Revised:  November 27, 2013

Mentor Research Institute

Prozac: Hazard to your health insurance

Reproduced under the Fair Use exception of 17 USC � 107 for noncommercial, nonprofit, and educational use

Concerned that ugly family fights were upsetting his young children, a Boston-area lawyer went to a therapist and let his health insurance pick up part of the tab. When the lawyer later decided to apply for more insurance, he was denied coverage specifically because he had the counseling visits on his record.

Sure, you can get the help you need to handle depression, anxiety or even something as common as hay fever. But should you ever need to buy an individual health policy, you're likely to find that insurers consider you high-risk or even untouchable. You're likely to pay more for a life or disability policy as well, and perhaps be denied a security clearance.

"To protect my patient's privacy, I no longer submit insurance claims for my services," said the man's therapist, Dr. Peter Gumpert, who these days accepts only patients who can pay out of pocket.

"The moment I give them a label, it can follow them for their entire life. I really worry about that," he said. "This whole thing has a chilling effect on people getting the help they need."

Health insurance on your own

Individual health insurers may deny you coverage based on your medical history or put you in such a high-risk category that it makes health coverage too expensive, according to Karen Pollitz, a Georgetown University researcher who co-authored a 2001 study on the individual health-insurance market for the Kaiser Family Foundation.

In her study, Pollitz found that roughly 90% of applicants in what's known as less-than-perfect health were unable to buy individual policies at standard rates, while 37% were rejected outright.

"It's very, very hard to get coverage now" in the individual health-care market, said Pollitz, who said underwriting standards have only tightened since her study.

Even counseling for grief or a sleeping or eating disorder can make someone ineligible, she said. So can being on medications for hay fever or acne, because insurers consider you a high user of medications, she said.

"Allegra will get you every time," said Pollitz. "They may deny you, they may increase your deductible, or give you a policy with no drug card."

It's all about risk: theirs

Insurers make money by avoiding the risk of paying high claims. The sickest 1% of their policyholders can make up 40% or more of claims.

"Insurers will look at your past medical history, ongoing, any pre-existing medical conditions, all to determine a sense of what that consumer's future risk might be," said Larry Akey, spokesman for America's Health Insurance Plans, a trade group representing most of the largest insurers.

Current medications and all health-care treatments are something considered by the insurance industry, especially in the market for individual health care.

The majority of Americans get insurance through their employers, who in turn pay a large portion of the monthly premium. Large groups of diverse workers help offset the risk for insurers.

The individual market is much more risky for insurers, however, because the individual pays the premium and there is not a diverse pool of people. The market for non-group insurance is a small one in the U.S., with roughly 6% of the population under 65 covered by such a policy, according to a study by the Rand Corp.

But a lot of very ordinary circumstances can force someone into this market, including:

  • Becoming self-employed.
  • No longer qualifying as a dependent on a parent's plan.
  • Getting a job that doesn't offer health insurance.
  • Coming to the end of your health benefits under COBRA, the federal health insurance safety net for someone leaving a job.

Industry representatives such as Akey said getting insurance in the individual market is not as hard as past studies have shown. They cite their own 2005 study, which found that about 88% of people who applied for individual coverage in 2004 were given it, and 77% of those paid standard rates.

Who needs help?

A 2005 Harvard survey found that most Americans have the symptoms for one or more mental health disorders at some time in their life, but most cases are mild. The findings:

  • Anxiety disorders, experienced by nearly 29% of Americans during their lifetime, are the most-prevalent class of mental illness.
  • Mood disorders are experienced by 20.8% of Americans.
  • Impulse-control disorders are experienced by 24.8% of Americans.
  • Substance disorders are seen in 14.6% of Americans.

Only 41% of patients with disorders lasting 12 months sought treatment, the study found.

In 2005, 357 million new prescriptions were written for psychotherapeutic drugs such as Ativan, Klonipin, Paxil, Prozac, Serzone, Zoloft, Xanax and Wellbutrin, a major increase from the 168.4 million new prescriptions that were written just three years earlier, according to Wolters Kluwer Health, a data company in Parsippany, N.J.

In addition, more and more children are taking such medication. In 1995, just 8.6 children under 13 out of 1,000 were on anti-psychotic drugs, compared to 40 out of 1,000 in 2002.

Among the public, the stigma about seeking therapy has lessened, said Carolyn Rabinowitz, president of the American Psychiatric Association, in part because of the willingness of famous actors, celebrities and athletes to publicly admit they have been treated for depression, postpartum depression or anxiety. Also, more and more people know someone treated for a mental health disorder who got well or improved, she said.

That hasn't made getting an individual insurance policy any easier, though.

"Anything they can do to exclude payment, they do. Their business is to not pay money," said Rabinowitz.

"It's gotten worse, and it's a real problem for people," agreed Bill MacGillivray, president of the National Coalition of Mental Health Professionals and Consumers, an association. "If you seek care you are seen as damaged by the insurance industry."

There's nowhere to go

In the arcane market for individual coverage, very few consumers seeking such insurance have protection under federal law.

In roughly a dozen states, such as Arizona, California and Delaware, the Health Insurance Portability and Accountability Act (HIPAA) requires insurers to sell a health-insurance policy without coverage limits to you if you have had at least 18 months of continuous coverage and are moving from a group policy to an individual policy. However HIPPA does not limit what can be charged.

"You'll tend to see horrific rate-ups when that is the only option insurers can apply," with premiums jumping double, triple or even 10 times higher than the average amount, said Pollitz.

Insurers do not disclose their underwriting guidelines and different insurers interpret diagnoses in different ways.

For the most part there is little rate regulation, with only five states -- Vermont, New York, Maine, New Hampshire and New Jersey -- guaranteeing access to the individual market at community-rated premiums not based on health status.

"There's been a lot more public awareness of non-group insurance -- it is not ideal in any way," said Gary Claxton, a vice president with the Henry J. Kaiser Family Foundation. "Almost any mental health issue can disqualify you in some states. Different states allow different things."

Properly nervous

A survey on medical privacy, released in November by the California Healthcare Foundation, found that 13% of American adults say they have done something "to protect the privacy" of their medical history. Younger respondents, those under 45, were more likely to have engaged in privacy-protective behaviors. Those include:

  • Paying out-of-pocket to avoid submitting a claim.
  • Not seeking care, such as diagnostic tests, to avoid disclosure.
  • Asking their doctor not to write down a health problem or to record a less-serious condition.
  • Giving inaccurate or incomplete information on a medical form.
  • Asking therapists not to take notes or to see a patient under an assumed name.

"People should not have to sacrifice their health in order to shield themselves from job discrimination and loss of health benefits," said Janlori Goldman, a researcher at Columbia University's College of Physicians and Surgeons. Still, there is a large number of "people fearful that their medical information will be used against them," she said.

There's good reason for such fears. Insurers share information through organizations such as MIB Inc., a Westwood, Mass., association of insurers that gathers health and other information on consumers, almost like a credit report.

MIB gathers information on those who have applied for insurance in the individual market, such as for life, disability or health coverage. That information is coded and shared with member insurance groups who receive new applications. A consumer is notified about MIB on the application. (A free report will be given to those consumers who request it by going to the MIB Group site.)

"An insurer's goal is to understand the consumer they are underwriting and properly gauge the risk. Otherwise, they would be insolvent," said David Aronson, spokesman for MIB, a not-for-profit group.

If you are looking for coverage in the individual market, be prepared for scrutiny. Health-care applicants are asked to fill out detailed, multipage questionnaires about their health care. Different insurers ask different things. One of the first questions after your name is usually whether you have diabetes, Pollitz said.

After they receive the application, insurers turn to information gatherers like MIB and other sources to double-check what an applicant has disclosed.

So now you need insurance

Lying on your health-insurance application form is never a good idea. Considered insurance fraud, the insurer can cancel your policy (just when you might need it) if you are caught. As more and more data is warehoused electronically, it is easier for insurers to share information about you. What you can do:

  • Answer the question to the best of your ability and be truthful.
  • Hire an experienced health-insurance broker who knows the underwriting criteria of several individual insurers.
  • After an appointment with a therapist, look at the number on the claim form you receive from the therapist. Ask what your diagnosis is, so you can best know how to proceed.
  • If you are denied, ask you doctor to write a letter supporting your re-application, especially if you are no longer in counseling or no longer taking a prescription drug that got you denied.

To learn more about protections for individual health insurance offered by your state, go to, a Web site run by Georgetown University.