Health insurance and risky behavior in COVID era

The Quarantine Zone
1

I’m intending this as more of a GQ-ish question, but put it here because it relates to COVID.

I have heard that some insurance policies have clauses that certain types of risky behavior may negate the benefits. For example, a life instance policy might not pay out if the person dies while skydiving.

Do health insurance policies have similar clauses? Because I’m seeing all these pictures of people engaging in behavior that is strongly discouraged or even prohibited - protests with people squished together or people sitting at bars without masks, and so on.

If Roger got COVID and had to go to the hospital, and someone in the health insurance company happened to see a news photo of Roger at a “Open Up America” rally where he was French kissing strangers and licking doorknobs, is it conceivable that the insurance company would have a strong case in denying a claim to pay for those medical costs?

I’m setting aside issues here of whether this is a good way to deter people from doing stupid things or another example of the failings of our private, for-profit health insurance system.

2

Doubt it. How would you prove that’s the exact instance he got it? Maybe he was perfectly fine at the rally, and contracted COVID-19 from a store worker while picking up toilet paper.

Whereas it’s pretty difficult to hide someone dying from skydiving, train-hopping or playing Russian roulette.

3

I thought the ACA made that plainly illegal?

Anyway I found an article about it.

I think that says health insurance exclusions and rescissions are only allowed (if that) in case of material misrepresentation at the time of application. Not for conduct afterward.

4

I think the only conceivable out they might have is that anything arising from an illegal act is not covered. When reviewing my travel insurance for a cancelled trip in March, if you are driving drunk they will not cover car damage, etc.

5

Does that actually make a difference though? Are you saying that if an insurance company WAS able to identify the precise second the insured was infected, they could deny benefits?

I know for sure that ACA prohibited the pre-existing condition issue, I just don’t know that it prohibited something like this.

For the cite, my read of that is that has to do with denying benefits based on a misrepresentation. But I don’t think it says that misrepresentation is the only reason benefits may be denied. Maybe it is, I’m not sure based on that cite.

If someone is cited by police for, say, violating the social distancing orders that are in effect for some jurisdictions, are you saying that would be a sufficient basis?

6

Health insurance in the U.S. is not fault based. They cover according to the terms of the contract. I can’t imagine a valid denial for getting COVID-19, regardless of how you got it. You’re covered if you’re speeding and have a crash. You’re covered if you accidentally cut your leg off with a chain saw.

I suppose they could draft a policy that doesn’t cover treatment related to a pandemic, but the ACA probably prohibits that kind of exclusion.

7

I’ve worked 15 year in health insurance (albeit not in underwriting, fraud, or any department directly related to the question) First, there’s different types of “negate the benefits”. There’s rescinding the contract- retroactively cancelling the policy, and there’s just not paying a claim due to it being a non-covered benefit while the policy stays active.

Rescinding is only done as a sanction for lying on the application. Non-covered benefits are a lot more broad. Acts of war are always listed but in real life the most common ones are third party liability, medical non-necessity, and committing a felony. I’ve also seen some behavior type exclusions on student and short term policies like skydiving, skiing, tackle football, self-harm, rioting and substance abuse, but never on commercial, ACA compliant policies.

8

Here is a cite that ACA made rescissions illegal. (Here is a link to the U.S. CFR that I think is just that part.) That’s just a cite for my statement, without addressing other possible ways they could deny coverage.

9

Not specifically, but they could write it in to new policies I guess. I’m not a law-talking guy so who knows if they could enforce it.

10

Where would you want it to stop? Even aside from potentially not covering anybody who plays any sport more risky than tiddlywinks:

“We’re not covering your stomach cancer because we’ve got a picture of you eating a hot dog.”

“We’re not covering your mental health treatment because you can’t prove you’re getting 8 hours of sleep each night.”

“We’re not covering your broken leg because you went outside when the weather report was predicting freezing rain.”

There’s a difference between a reasonable risk and an unreasonable one, yes. But that line is essentially blurry in the middle; and even where many think it’s less blurry people are going to differ about where the line is. Putting the decision in the hands of an entity whose profit is affected by shoving it way over sideways is a bad idea.

11

Life insurance is certainly rated based on if you are a smoker or not.

12

This is a very clear answer, thank you!

I wished I said in the OP that I wasn’t interested in whether this was a good idea, because I was just wondering if it was allowed.

Oh wait, I did.

13

Yes, on re-reading I suppose that you did. I’ll drop the subject.

14

The OP is specifically asking about health insurance which isn’t quite the same as life insurance. It’s true that your health insurance premiums might be affected by your blood sugar, obesity, blood pressure, body mass index, and whether or not you use tobacco products. But your health insurance provider can’t just decide not to pay out because because you did something stupid and got sick or injured.

15

I’m glad to be Canadian where residency automatically gives me health coverage without deductibles, co-pays, pre-existing conditions, and the concept of “In Network”.