Finding health insurance at affordable rates is difficult, especially for people with epilepsy, but it is available. Insurance companies generally believe that persons with epilepsy are likely to cost the company money by submitting large or frequent claims. The type and severity of seizures, and the seizure free period will probably be taken into account in determining whether to provide coverage to the individual. When applying for individual insurance plans, providing detailed information from one's doctor about one's specific situation can be helpful, particularly if the seizures are controlled.
Types of Coverage
There are many different types of insurance coverage/plans available including group benefit plans, HMOs, Medicare, Medicaid and individual insurance policies. The most effective, least restrictive and least expensive way to obtain health insurance is through your employer. If you are not employed or if your employer does not offer insurance, it is extremely important to "shop around" to obtain individual health insurance and to get the broadest coverage at the lowest rates. Companies can refuse to underwrite insurance policies for people with epilepsy. However, some companies will underwrite (approve) policies but will exclude coverage for epilepsy and related expenses or they may require the individual to pay a higher deductible. Since policy-writing practices vary so much among companies, rates and conditions differ significantly. It may be helpful to contact an insurance broker for guidance, as they are familiar with eligibility guidelines as well as the practices of insurance underwriters doing business in the state.
Federal Laws that Help
Strides have been made through federal legislation to help individuals obtain and maintain insurance coverage as well as to limit the evils of "pre-existing condition" clauses that affect so many people with epilepsy. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) limits the amount of time insurers can deny coverage for pre-existing conditions to twelve months provided the policy includes coverage for the condition. HIPAA also prohibits insurers from charging different premiums based on an individual's health status. However, as long as the discriminatory coverage is based on sound actuarial data, an insurer may deny coverage for particular conditions or treatment.
The Comprehensive Omnibus Benefits Reform Act of 1986 (COBRA), a second federal statute, can help people retain coverage when they have left a group health plan. Individuals, who are no longer eligible for group health coverage due to a qualifying event, can purchase COBRA coverage for up to 18 months (this may be extended in limited circumstances). COBRA and HIPPA can work together to: 1) maintain coverage while finding or starting a new job, and 2) limit pre-existing condition periods that may apply to a new insurance plan.
State Laws That Help
States have become increasingly active in restricting insurance discrimination, particularly for health care. Many states now have laws that can provide additional protection to individuals, but these laws vary significantly from state to state. Commonly, these laws prohibit discrimination in insurance on the basis of disability unless the discriminatory treatment is based on sound actuarial data. In addition, some states have passed various types of insurance reform laws which may make it easier for someone with a pre-existing condition to get insurance and/or which create a plan for those who cannot get insurance through the private market.
An ADA Remedy?
Refusing to provide coverage for certain conditions may also give rise to a claim under the Americans with Disabilities Act (ADA). Unfortunately, on the Federal level, courts disagree on whether the Americans with Disabilities Act (ADA) provides protection in regards to health insurance policies that provide different amounts of coverage for different disabilities. Under Titles I & II, employers and public entities (which includes states and their departments and agencies) that provide health insurance do not have to provide the same coverage for all conditions, so long as they offer the same policy to all employees. Under Title III, insurance companies are only required to provide equal access to policies, not equal coverage for all disabilities and conditions. Under all Titles, differential treatment is permitted so long as it is based on sound actuarial data. For additional information regarding ADA claims based on discriminatory insurance practices, contact an attorney or disability law center in your area.
Regulating the Insurance Industry
The state insurance commission regulates the insurance industry in your state. If you are denied insurance coverage due to your epilepsy, you may want to consult the Commission about whether the insurer's actions were legal under your state laws. The Commission can often assist with questions about state insurance regulations and an individual's rights in regard to insurance coverage. For your state's insurance commission information, contact our Information & Referral Department at (800) 332-1000.