Underwriting Guidelines

“We Believe Health Insurance is A Right Not A Privilege”

Underwriting before Obamacare could get very intense on individual health insurance policies.  Many people think that the stories of health insurance companies underwriting are untrue or exaggerated but I am here to tell you that it was very difficult to get improved with no qualifications on your policy, meaning no exclusionary riders or rate increases.

Several years ago, there was a news story about a rape victim being denied coverage for a particular exam due to her being a victim of rape which is just an example of how vicious these health insurance underwriters could get.

 

East Coast Health Insurance

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Please send your Health Insurance Underwriting Questions to East Coast Health Insurance or call us anytime @ 888 803 5917.

Firstly, as my wife (who is one of the owners of East Coast Health Insurance) often tells our health insurance agents when they ask the same underwriting question for the millionth time, “Go Check The Underwriting Guidelines!”  So rather then go into a long-winded explanation of the different health insurance companies and their various underwriting guidelines in different states I figured why not just post the underwriting guidelines themselves?  It will be the first time it has ever been done in one place.

Firstly, here are some of the highlights that we use to educate our new agents during our product trainings:

Note that any plan features regarding pre-existing conditions, BMI, waiting periods or exclusions apply before the health care law took effect.

 

AvMed

 Lenient underwriting guidelines (especially with BMI) and is the only carrier to counter offer applications
 Easy application process including submitting an application using a paper app signed by client, starting and sending application to client to e-sign
 Only carrier to offer monthly payments to be done on automatic debit using a Mastercard or Visa
 No waiting periods imposed for preventive care or other medical services
 Prior creditable coverage is applied and waives 24 month waiting period on pre-existing conditions
 Limited to South Florida (Miami Dade and Broward) – outsources national network using PHCS (not available on HMO plans)
 Co-payments cover many of the regular medical services rendered throughout the course of the year (labs, x-rays, Emergency Room, urgent care, complex imaging, etc)
 Maternity Benefits Available

Cigna

 Lenient underwriting, also accept Diabetics Type II
 Competitively rated, only in the individual market since 2009
 Prior creditable coverage is applied and waives 24 month waiting period on pre-existing conditions
 6 MONTH WAITING PERIOD imposed on the following unless it is a medical emergency
 Hernia
 Any disorder of the reproductive organs
 Varicose veins
 Hemorrhoids
 Any disorder of the adenoids or tonsils
 Gallbladder

Humana

 3 MONTH WAITING PERIOD for preventive care services
 3 MONTH WAITING PERIOD for non-emergency removal of tonsils or adenoids
 6 MONTH WAITING PERIOD for non-emergency treatment of bunions, varicose veins, hemorrhoids or hernia (does not include strangulated or incarcerated hernia)

United HealthOne

 Good prescription drug coverage especially for mental health medication
This assumes that policy includes OPTIONAL ENHANCEMENT – NO MAXIMUM PRESCRIPTION BENEFIT since normal limit is $3000 annually
 3 MONTH WAITING PERIOD for preventive care services
 6 MONTH WAITING PERIOD for any expenses incurred for treatment of the following:
 Tonsils
 Adenoids
 Middle Ear Disorders
 Hemorrhoids
 Hernia
 Any disorder of the reproductive organs
 Emergency basis would be covered, “emergency” meaning manifesting itself by acute signs or symptoms that could reasonably result in placing a person’s life or limb in danger if medical attention is not provided within 24 hours.
note: Pre-existing Conditions are not covered during the first 12 months to 24 months depending on the insurance carrier. A pre-existing condition is an illness or injury for which a covered person received medical advice or treatment within 24 months prior to the applicable effective date for coverage of the illness or injury; or which manifested symptoms which would cause an ordinarily prudent person to seek diagnosis or treatment within 12 months prior to the applicable effective date for coverage of the illness or injury.

Health Insurance Company Underwriting Guidelines

  • Cigna UW Guidelines
  • United Health Care UW Guidelines Updated 10.2009 UHC
  • Aetna Underwriting Guidelines Aetna UPDATED May 2009
  • Humana Underwriting Guidelines
  • Blue Shield of California Underwriting Guidelines
  • Health Net Underwriting Guidelines
  • PacifiCare Underwriting Guidelines
  • Vista South Florida Underwriting Guidelines
  • Avmed Florida Underwriting Guidelines

 

Ask Us Your Underwriting Questions on Individual Health Insurance Policy Underwriting

Question: I have been diagnosed with APNEA and I use a CPAP (AIR PUMP) every night with great results. Now, my previous insurance advisor tells me that United will not take me with that condition. Is that true?  It does not make any sense to me so I told her that I would look around by myself (that means, asking you for a policy that covers my wife and myself together).

Pre-Health Reform Answer: I did check the underwriting guidelines for United and indeed it indicated that Sleep Apnea was a declinable condition.  Humana riders out the condition as you currently have it controlled with CPAP; if it was surgically corrected you would have a preferred rating with Humana.  I would also suggest trying Aetna, although they could rate up your premium up to 150% we can see how they come in on their final proposal after the underwriting process.  Please note that with Humana if you have High blood pressure or a ratable build along with the sleep apnea, then it would be a decline.  The condition on its own is ridered out, but couple that with another condition and they would probably decline you.  I know that sounds terrible, but all insurance companies are pretty strict with the individual underwriting.

Under health reform, however, all individual insurers are required to accept applicants with sleep apnea or any other condition.


Question: Are PPO’s allowed to issue Exclusionary Riders and Rate Ups on Individual Policies (before health reform)?

Yes. PPOs were allowed to issue exclusionary riders and rate increased on an individual’s policy before the Affordable Care Act changed underwriting rules. HMOs and POS cannot since they are filed as an HMO and as per state law cannot issue exclusionary rider but could impose rate increases before the law took effect, as well.  This is not the same thing as the 24 month pre-existing clause in which states that for either 12 months or 24 months depending on the company – that they will not cover any pre-existing condition if you do not have proof of creditable coverage.  Although, some health insurance companies were somehow able to issue policies and still impose a 12 month waiting period regardless of whether or not they had creditable coverage within 62 days of obtaining new coverage. Now, no insurer can impose a waiting period, elimination rider, or rate up on your plan, even as a PPO.

 

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