After you submit your California individual health insurance application, a person (the health carrier underwriter) will go through a completed application and make one of two decision.  Either the underwriter will make a decision as he/she feels there is adequate information to process the application or the underwriter will request medical records from a doctor/hospital or other medical provider listed in you health history questionnaire section.  This can delay the underwriting process quite a bit.  Let's look a little deeper into why medical records are requested and how it works.

How the request for medical records works

In most cases, the applicant does not need to do anything.  The carrier will either contact the doctor's office directly or use a third party company to do so.  WFI is currently the large third party company that many major California health insurance carriers use.  If the underwriter sees an issue in the health history section that is ambiguous (could be bad or good depending on status in doctor's notes), he/she will initiate the medical record request.  A notification will go to the doctor's office to let them know of the carrier's request and to set up an appointment to come and make copies.  Each doctor's office is different but most require a pre-payment (generally around $25) which the carrier pays. The doctor will then schedule a date for the carrier or it's representative (WFI for example) to come in and make copies.  The request may be specific to a given condition, time range, or sometimes, a request for all medical records. 

Why do medical record requests delay the underwriting and application process?

Once the carrier has the records in house, we usually have a decision in 5-7 business days depending on the carrier.  The delay can come in how long the doctor/provider takes to respond.  Most doctor offices are pretty good at turning these requests around in 5-7 business days.  Some, however, are very slow if not un-responsive.  Kaiser is usually pretty slow as well.  Kaiser is both the insurer and the provider.  We have seen providers take over one month to provide records and some never reply.  Without the medical records, the carrier cannot continue or finalize the underwriting process. 

What if my doctor's office is not responding to the carrier?

As they patient, you have the right to get your own medical records.  We usually advise the health insurance applicant to call the doctor's office just to remind them of the request in process and apply some gentle pressure so that it stays on their radar.  You can also go get the records yourself and then we can fax them directly to the health insurance underwriter.

Questionnaires sent directly to the application

Some carriers will send questionnaires directly to the applicant.  This is a more in-depth form that the applicant can fill out in regards to a particular health issue or pre-existing condition.  Try to complete and fax or mail this back as quickly as possible to allow the underwriting process to continue.  This is more common with mental health issues or less serious medical issues.

Medical records request and the chance of application approval

The fact that a health insurance carrier request medical records does not mean you are less likely to qualify for coverage.  In our experience, about 60-70% of applicants have medical records request.  By itself, it is not a red flag.  The underwriter just needs more information to make decision.  Tonik is a simplified issue plan where the underwriter is not able to request medical records.  This is both good and bad depending on the applicant's health history.  It can be a pretty fast process but a person might be declined with Tonik health insurance even though he/she could qualify for the standard plans if the underwriter was able to request records and gain more complete information.

Other important concepts to help you understand your California health insurance quote are:

Question on the individual health insurance application
Individual health insurance underwriting
Enrolling for Individual health coverage in California
Download the health application or apply online
What can delay your individual health application
Options for people who do not qualify

To run your instant health insurance:

California Individual Family health insurance quote
California group health insurance quote