Do Health Insurance Premiums Go Up Every Time You Make a Claim and Get Medical Care?

Health insurance premiums are a significant consideration for many individuals, families, and employers. One commonly held belief is that health insurance premiums increase whenever you make a claim or access medical care.

However, the reality is more complex. Let’s delve into this topic to gain a clearer understanding.

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What are Health Insurance Premiums?

Health insurance premiums are the payments made (usually monthly) by individuals or their employers to insurance companies to maintain coverage. 

These premiums can vary based on numerous factors, including age, geographic location, size of the family covered, type of plan, and the overall health of the group insured.

Factors Affecting Health Insurance Premium Increases:

1. Claims Experience

This refers to the number and type of claims made by members of a policy group over a certain period. If an insurance company sees that a particular group (like employees of a company) consistently have higher medical expenses, they may raise premiums for that group. 

However, for individual policies, claims made by one person generally don’t lead directly to increased premiums for that specific individual. 

Instead, premiums may increase based on the collective claims experience of all policyholders within that insurance plan.

2. Medical Inflation

The increasing cost of medical services, equipment, and medications contributes to rising insurance premiums. As healthcare becomes more expensive, insurance companies may adjust premiums to ensure they can cover their policyholders’ expenses.

3. Healthcare Regulations and Legislation

Laws and regulations can also impact premiums. For instance, mandates that require insurance companies to cover specific treatments or services can lead to increased costs and, consequently, higher premiums.

4. Administrative Costs

Insurance companies have overhead costs, including salaries, marketing expenses, and other administrative expenses. An increase in these costs can result in higher premiums.

5. Changes in Covered Population

If an insurance company covers more high-risk individuals (such as older individuals or those with pre-existing conditions), premiums may go up to balance out the risk.

Do Individual Claims Result in Direct Premium Increases?

However, group policies (like those offered by employers) may see a rate increase if the collective claims of the group exceed what the insurer anticipated. Even then, this is about the entire group’s experience and not about individual claims.

Several regulations and consumer protections exist, especially after the implementation of the Affordable Care Act (ACA) in the U.S:

  • Insurance companies can’t raise your rates solely based on your health status or a pre-existing condition.

  • There’s a process of review for any proposed rate increases, ensuring transparency and offering an opportunity for state officials to scrutinize the justifications behind the rise.


While it’s a common misconception that individual claims directly lead to increased health insurance premiums, the truth is more nuanced. 

Premiums are influenced by a blend of factors, including the collective claims experience, medical inflation, and administrative costs. 

While individual claims don’t lead directly to premium increases for that individual, being a part of a high-claim group (like an employer’s plan) can lead to increases for everyone in that group. 

Understanding the dynamics behind premium costs can help consumers better navigate and make informed decisions about their health insurance.