A Sample Short-term Health Insurance Application

We’ve written about short-term health insurance coverage as a viable alternative for individuals and families who are having trouble getting major medical health insurance coverage due to height/weight restrictions or other pre-existing conditions. The limited duration of these policies makes them a more affordable option. The very limited underwriting makes it a viable option for many people who can’t otherwise get major medical health insurance protection. Here’s a sample short-term health insurance application:

Please answer the medical questions below as they apply to all individuals included in this application.
Question 1: Will any applicant have other health insurance in force on the policy effective date or be eligible for Medicaid?

Question 2: Have/Are you, or any applicant
a. Been denied insurance due to any health reasons for a condition that
is still present (Does not apply to residents of MO)?

     b. Now pregnant, in process of adoption or undergoing infertility treatment?

     c. Over 300 pounds if male or over 250 pounds if female?

Question 3: Within the last 5 years has any applicant been diagnosed or treated by a physician or medical practitioner for Acquired Immune Deficiency Syndrome (AIDS) or tested positive for Human Immunodeficiency Virus (HIV)? Residents of WI do not need to disclose HIV test results.

Question 4: Within the last 5 years has any applicant been diagnosed, treated, or taken medication for or experienced signs or symptoms of any of the following: cancer or tumor, stroke, heart disease including heart attack, chest pain or had heart surgery, COPD (chronic obstructive pulmonary disease) or emphysema, Crohn’s disease, liver disorder, degenerative disc disease or herniation/bulge, rheumatoid arthritis, kidney disorder, diabetes, degenerative joint disease of the knee, alcohol abuse or chemical dependency, or any neurological disorder?

Question 5: If you are not a US Citizen, do you expect to legally reside in the US for the duration of the policy?

If you have answered “Yes” to questions 1 through 4 or “No” to question 5, coverage cannot be issued.

If you pass this short application, you can apply for a short-term health insurance plan and have coverage as soon as tomorrow. Contact us if you have questions or need more information.