Rejected by Kaiser


New Member
My wife applied online to Kaiser (we live in Northern California).

I have been a member for some years and it made sense for us to be on the same plan. (I was told that the thing to do was to have her apply separately, then after she is accepted, to merge her account with mine.)

Her application was rejected later the same day. Two reasons were given.

The first reason given relates to one question on the application:

"Within the past three years have you been advised to have, but have not yet had, surgery, treatment, examination, or test for any medical condition?"

We filled out the online application together very carefully and answered this question with a "no." Yet somehow it came out answered "yes."

The second reason given for rejection was height/weight proportionality. My wife is 34, 5'4", 98 pounds (no significant health issues or history of illness, hospitalization, etc.). Among Asians, this is not unusual. She is small-boned and slender, not emaciated or unhealthy.

Can anyone offer any suggestions as to how we might appeal this rejection or give us any insight into this process?

If we cannot get her into Kaiser, we will explore other possibilities but we would first like to see what we could accomplish with Kaiser.
The yes answer kicked the application out.

I only have underwriting criteria for KP in GA, but I would assume they are the same or similar to KP in CA. The ht & wt guidelines for 5' 4" is 100#.

In some cases underweight can present just as many, if not more issues than being overweight.

Take John's advice and get with a local agent. He/she may be able to appeal on your behalf to KP. Getting them to reverse an underwriting decline can be done but it is not easy. You may be better off with some other carrier.
Exactly, find an experienced agent that will know what questions to ask and what issues underwriting will have.

I'm not a fan of buying insurance online. There is almost no way of knowing everything about what you're purchasing at the time of sale and I think it's a potential disaster for the average person with no particular industry knowledge.
Highly unliked Kaiser will reconsider. I know it was a mistake but answering "yes" to that question is a deal killer. More than likely the only way they'd reconsider is by ordering doctor records showing that you don't have any scheduled procedures. And if you're below their weight limits that's also a very rough road - and like stated above, underweight is actually harder to get through underwriting than overweight.
One problem is that Kaiser CA does now allow us to act as servicing agent on any individual & family policies, so an agent can't help you with this as kaiser requires it all be direct. We get a "referral fee" for each applicant that uses us, but we cannot act in the same capacity as we do with Blue Cross CA, Shield, Net and so on.

You can file a request for reconsideration with Kaiser and also contact the Dept of Managed Health Care about appealing (there might be appeal process information in the communication you received from Kaiser).

In my experience, your chances of getting an individual & family plan through underwriting really depend on the carrier.

Kaiser and Health Net are the strictest and decline way more of mine than they accept. Many conditions deemed acceptable for consideration from other carriers are automatic and lifetime declines from Kaiser and Health Net. Pacificare is tough, too, but they are in flux right now since UHC bought them and no one is exactly sure who runs what over there.

Shield is better in underwriting, some things tough and some more flexible (infertility is a good example - lifetime decline with KP and HNet, 5 years with Cross and only 2 years with Shield).

In my experience, Blue Cross CA has the best underwriting and if they say no, then don't even bother with the others. I have placed many declined cases with Cross and some at standard premium.

That is kind of the landscape in California. I envy you guys in other states that are allowed to fully broker with Kaiser on the IFP side. Here, well the referral fee is better than turning people away but I am not a big fan of being out of the loop when it comes to underwriting or claims issues.

Dave Fluker
Often times, it does NOT make sense for a husband and wife to be on the same plan. You will have different needs, and it is sometimes more expensive to insure a husband and wife, then to do so separately as individuals (I know, you were trying to do it separately)
Specifically, some carriers assume that h&w will be more likely to have a maternity claim. Also, if there is an age discrepancy that spans an age band, you will usually be better off with two separate policies. In addition, if one has bad claims and gets a big rate up, they only have the rate up for one of them.
Dave020 said:
One problem is that Kaiser CA does now allow us to act as servicing agent on any individual & family policies,

In CA on individual (non-group) plans Kaiser pays agent flat $100, one time (no renewal). Thus, most agents don't bother with Kaiser... but I will when I have the time.

Find an agent and re-apply. You might get a different outcome. Kaiser is known to have some quirky computer systems... and underwriters.

If you are in Northern CA, call me and I'll help. Or call Dave as he is just down the road from me.

Actually, $100 flat per member initial enrollment and $50 renewal enrollment per member. It's not a bad deal, however it does not allow full'
agent servicing like the other carriers. That makes it less attractive to us
as really that is what you are paying commission for.

Dave020 said:
Actually, $100 flat per member initial enrollment and $50 renewal enrollment per member. It's not a bad deal,

You're right about the renewal. I confused Kaiser with another plan.

Why you think this is 'not a bad deal' is beyond me. You bring $3,000 worth of business to them and you get a 3% commission? Hey, come work for me. I'll do better and give you 5% commission on ALL the business you bring ME :-)