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Ask The Insurance Decoder

Lynne Lucio

Lynne Lucio

By Lynne Lucio

Q.  What’s the difference between an individual health insurance policy and group health insurance coverage and how can I obtain either one of these policies?  —Emily T., Carmel, CA

A:  Good question and one that confuses many people.  Individual health policies are a type of health insurance coverage that an individual can purchase directly from an insurance company.  As a rule, to obtain individual insurance the person must complete a health questionnaire for underwriting purposes and often must submit to a medical examination in order for the insurance company to determine what, if any, health conditions will be limited or excluded from coverage.  Although Healthcare Reform hasn’t determined final guidelines, it’s likely that medical exclusions won’t be allowed on individual plans in the future.

On the other hand, since group health coverage is employer-sponsored coverage, to obtain group health insurance and individual must be eligible under his/her employer-sponsored health plan.  This type of coverage rarely requires a medical questionnaire or exam because the insurer can usually cover enough people in the group, which allows them to balance people in poor health against healthy individuals.  In addition, Healthcare Reform will no longer allow pre-existing condition restrictions in group health plans beginning January 1, 2014.

ASK The Insurance Decoder © Copyright 2012, Lynne Lucio.  All rights reserved.  
Lynne Lucio, the author of The Insurance Decoder:  How to Maximize Your Health Insurance Benefits, Minimize Out-Of-Pocket Expenses and Stay One step Ahead of Your Insurance Company, has been a health insurance professional for over 20 years.  As an insurance insider, Lynne learned how to decipher the medical claims labyrinth and developed the specific and practical knowledge of the claims process.  Throughout her career, Lynne has shared her expertise with thousands of insured consumers, helping them resolve complicated health claims while showing them how to take full advantage of their health insurance benefits.  The depth and breadth of Lynne’s knowledge of the topic encompasses not only the claims process but also the laws that influence and regulate health coverage, including ERISA, COBRA, FMLA, USERRA, HIPAA and others.  Lynne provides consulting services to covered individuals and writes about health insurance issues on (  For more information, or to submit your own health insurance related questions, contact Lynne at

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