Health Insurance Basics

Accidental Bodily Injury

An unforeseen and unintended injury that resulted from an accident rather than a sickness

Disability Income Insurance

A valued contract or stated amount that pays weekly or monthly benefits due to an injury or sickness. Benefits may be determined by the insured's past earnings and may be limited to a percentage of that income

Medical Expense Insurance

This contract covers many of the expenses one incurs from an accident or sickness, such as a physician or hospital expense

Dental Expense Insurance

This is a form of medical expense health insurance that covers the treatment, care, and prevention of dental disease and injury to the insured's teeth

Long-term Care Insurance

This contract provides benefits for medically necessary services which one receives in a nursing home or at one's own home

Three most important underwriting factors for classifying health insurance applicants

- Physical condition of the applicant and other insureds
- Moral and Morale Hazards
- Occupation

Government Health Care

- Medicare for people older than 65 (sponsored federally)
- Medicaid for poor people (sponsored federally and by the state)

Limited vs. Comprehensive Health Insurance

- Limited would cover specific accidents or diseases, must state that they are a limited policy notice on the first page of the policy
- Comprehensive would cover all accidents or diseases unless specifically excluded in contract

For a self insurance program to be dependable it must:

- be big enough to permit the use of a sufficiently large number of exposure unites so as to losses predictable
- the plan must be financially dependable
- the individual units exposed to loss must be spread in such a manner as to prevent a catastrophic l

Types of Limited Policies

- Accident Only (Accidental Death & Dismemberment or Travel Accident)
- Specified (Dread) Disease
- Hospital Indemnity (based on number of days in hospital)
- Credit Disability
- Prescription Drugs
- Vision and Hearing Care
- Critical Illness (pays lump-s

Common Exclusions from Coverage

- War or Act of War
- Intentionally Self-inflicted Injuries
- Conditions covered by workers compensation
- Government Plans
- Participation in criminal activities

Field Underwriting

It is the agent, not the home office underwriter who has direct contact with the applicant. He is responsible for clearly and precisely asking question and recording responses accurately.

An insurance agent or company cannot disclose any personal or privileged information about an individual unless:

- a written authorization by the individual dated and signed within the last 12 months has been provided
- or information is being provided to one of the following:
- an insurance regulatory authority or law enforcement agency; pursuant to the law
- an af

Application Procedures

- notice of information practices
- completeness and accuracy
- signatures
-changes in the application (applicatns must initital the correct asnwer)
- premiums with the application

Requirements at the delivery of policy

- Policy review
- Statement of Good Health
- Receipt

Sources of Underwriting Information

- Application
- Producer Report
- Attending Physician
- Investigative Consumer
- Medical Information Bureau (MIB)
- Medical Examinations and Lab Tests (Including HIV consent)