Sign of the times: Insurers scrambling to add coverage exemptions for insurrectionists & rioters

Among the most celebrated & ballyhooed provisions of the ACA are the Guaranteed Issue and Community Rating rules:

...Prohibits a health plan ("health plan” under this subtitle excludes any “grandfathered health plan” as defined in section 1251) from: (1) imposing any preexisting condition exclusion; or (2) discriminating on the basis of any health status-related factor. Allows premium rates to vary only by individual or family coverage, rating area, age, or tobacco use.

Requires health plans in a state to: (1) accept every employer and individual in the state that applies for coverage; and (2) renew or continue coverage at the option of the plan sponsor or the individual, as applicable.

Prohibits a health plan from establishing individual eligibility rules based on health status-related factors, including medical condition, claims experience, receipt of health care, medical history, genetic information, and evidence of insurability.

...Requires health plans that offer health insurance coverage in the individual or small group market to ensure that such coverage includes the essential health benefits package. Requires a group health plan to ensure that any annual cost-sharing imposed under the plan does not exceed specified limitations.

Prohibits a health plan from: (1) applying any waiting period for coverage that exceeds 90 days; or (2) discriminating against individual participation in clinical trials with respect to treatment of cancer or any other life-threatening disease or condition.

OK, so insurance carriers have to accept anyone who wants to enroll, has to cover most major medical services, and can't vary premiums based on anything other than how old they are, where they live, whether they smoke and how many people are in their household.

I had to remind a lot of people about this back in the summer of 2021 when a lot of people were calling for anti-vaxxers to have to pay higher premiums.

However...there are limits. For instance:

Prohibits a health plan from rescinding coverage of an enrollee except in the case of fraud or intentional misrepresentation of material fact.

In other words, if you lie about how old you are, where you live, whether you smoke, etc. (or your premium payment bounces), then yes, your insurance carrier can indeed drop you.

I mention all this because of an interesting article I saw today from Insurance News Net:

Be forewarned: If you injure yourself while participating in an insurrection against the government, don’t expect your health insurer to pay your medical expenses.

Very quietly, a number of healthcare insurance companies have added “insurrection” and “riots” to their list of excluded benefit payments, apparently in reaction to the Jan. 6, 2021 attack on the U.S. Capitol. It’s not known if any of the actual Jan. 6 insurrectionists filed injury or sickness claims but, in keeping with insurers’ strategies of limiting risk and exposure, the companies have sought to head off any future potential losses from political riots. Or, perhaps they’re expecting some political unrest in this election year.

The 2024 Cigna Health Care insurance policy excludes "treatments of an injury or sickness which is due to war, declared or undeclared, riot, or insurrection.” Aetna also excludes losses "caused directly or indirectly by invasion, insurrection, riot, civil strife, or civil commotion."

Insurers have sometimes listed “war” as coverage exclusions in policies, but the addition of “insurrection” and “riots” seems new.

The article goes on to note that the exact definition of a "riot" in particular can be a bit fuzzy.

However, this story led me to run a quick search about the issue, and I found a few other noteworthy stories:

According to the Kevin Kulik Professional Association:

...What is not considered are the additional costs that may be attributed if an injury, harm, or damage resulted from the alleged offense. For example, if you are injured as a result of the alleged activity you are being charged with, what happens if your health insurance decides to deny coverage for those issues?

...Many insurance companies have provisions within their terms and conditions that allow the insurance company to deny coverage when an injury occurs as a result of illegal activity. The purpose of the provision was to protect insurance companies for having to pay out and incentivizing illegal activities and crime. However, criminal defendants who are arrested but are ultimately acquitted may still pay the price even if they are not responsible for what occurred, and are injured or harmed as a result.

...The provision, known as the “illegal act exclusion,” provides that if an injury resulted from the commission of a felony. The scope of this exclusion has been applied broadly to not only felonies, but to misdemeanors and traffic infractions. The exclusion can also touch a person who is injured as a result of a felony, misdemeanor or traffic infraction but who was not actually convicted or charged with a crime.

There's also this story via MedicalJustice.com

A DUI is an illegal act. No surprise. Many insurance policies have language that denies coverage for illegal acts. 

At least 18 states have laws or regulations relating to illegal act exclusions, according to the National Conference of State Legislatures (NCSL). States allow or prohibit the exclusions in a wide range of insurance policies, including health, life, and long-term care. In addition, the breadth of the exclusion varies significantly among states.

For example, California allows a long-term care insurer to deny coverage for “participation in a felony, riot, or insurrection” (Cal. Ins. Code § 10235.8), while Iowa excludes coverage for “any injury incurred during the commission of, or an attempt to commit, a felony or sickness incurred while engaging in an illegal act or occupation or participation in a riot” (Iowa Admin. Code § 191-71.14(8) (38)). 

According to the National Institute of Alcohol Abuse and Alcoholism, 25 states explicitly permit drug and alcohol exclusion clauses in health and sickness policies, 16 states and the District of Columbia explicitly prohibit such clauses, and 10 states do not have provisions explicitly allowing or prohibiting the clauses. 

In states that allow denial of coverage for alcohol and drug related injuries, carriers are not required to include such exclusions.

...Federal law is silent on excluding such clauses. And many insurance policies are not state based. They are company sponsored and beholden to ERISA, a federal law.

Regardless of state law, self-insured companies that pay their employees’ health care costs directly can refuse to cover employees for alcohol-related claims.

So remember, if you're a Trump supporter who attempts to storm the Capitol a year from now to prevent the Electoral College votes from being certified again, don't expect Blue Cross to pay for stitches when you cut your hand open breaking one of the windows.

Of course, I can also see plenty of opportunity for these exemptions to be abused as well. Let's say you participate in a peaceful march but you trip & fall on the sidewalk, forcing you to get some x-rays. A few minutes after you leave the police decide to aggressively break up the march & arrests are made. Your carrier denies your claim. You then have to take them to court & prove that your injury happened before things got ugly, and so forth.