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SHOPPING FOR HEALTH INSURANCE.
Company Rating
AM BEST publishes the Ratings for all Insurance Companies. These Ratings are
based on Financial Stability and Claims-Paying Reliability. NEVER consider
purchasing Health Insurance from a company with less than an A- Rating. ASK TO
SEE THE AM BEST RATING CARD.
Health Insurance premiums are based on one of two ages.
ATTAINED AGE – Your present (attained) age, and ISSUE AGE – Your age at the
time of policy issue. Most Life and some Health plans use this age. However, the
majority of Health plan premiums are determined by your Attained Age. That is one
reason they increase at least once each year (12-28%). Your individual Claims
experience may, or may not cause your premiums to increase. ONLY a few
companies still offer Issue Age premiums. These may, or may not increase,
but they are certainly less likely to. In addition, when they do increase,
it is at a much lower rate.
ASK YOUR AGENT WHICH AGE HIS PROPOSED PLAN USES.
RENEWABILITY
There are ONLY 2 Renewal options. They are: A. GUARANTEED Renewability and
B. OPTIONAL/CONDITIONAL Renewability. All but two Health Insurers in SC offer
B only. The majority of insureds are 30-45 days away from receiving a Notice of
Cancellation from their Carrier, regardless if it is Group or Individual coverage.
That is all SC Insurance Law requires from a Carrier.
ASK YOUR AGENT WHICH OPTION HIS PROPOSED INSURER OFFERS.
“Will an Individual Plan cost more than a Group Plan?”
NO. Premiums for a “True Group” (usually 15 or more employees) are based on a
specific category/classification of employees, engaged in a similar occupation or
location. For various reasons, some businesses are rated higher than others. The
Carrier requires the “True Group” Employer to pay at least 75% of the premiums
for ALL eligible employees, regardless of their medical history or condition. The
Employee ALWAYS pays Spouse & Dependent coverage. Due to the average
Spouse/Dependent risk, premiums are usually rated in favor of the greatest risk
for recurring claims - women & children. Additionally, there is a charge for
Maternity Benefits - whether you need them or not. Employee rates are usually the
same for either Male or Female. THEREFORE, since an Employee’s coverage is
Employer-paid, the Employee can usually shop around to find similar coverage for
his/her family at a much lower rate with an Individual Plan.
“What is the BEST option for Affordable Health Insurance?”
By Far and Away, It’s an HSA!!!
The 2003 Medicare Reform Act included a provision for cost-conscious
consumers to set up a Health Savings Account. Since January 2005, it allows
consumers to take a 100% tax deduction for ALL medical-related expenses.
Unfortunately, due to many self-serving insurance agents & their brokers, the
public has not been properly educated on its tremendous benefits. Essentially, an
insured can reduce premium costs an average of 40-60% by purchasing a plan
with a $2k, $3k or $5k deductible.
(NOTE: This scares away a lot of people who would truly benefit from it)
HOWEVER, the real advantage is realized when a portion of the premium savings
is invested in a qualified, tax-free, interest-bearing savings account.
The Insurance Carrier issues a Debit Card to use for any medical expenses (even
band-aids). Up to the Deductible, any amount may be deposited into this account
every year. Some smart individuals roll over a CD or another Savings Plan into
this account to cover the deductible, then build from there.
Any unused funds at the end of each year roll over to the next and continue to do
so until used, OR until age 65. If you are over 55, there is a $600/yr per insured
“Catch-Up” provision. After the Deductible is reached, deposits may be
discontinued at any time. Funds remaining at age 65 may be rolled into any IRA
or Immediate Annuity to supplement other Retirement income.
What’s more, once the deductible is met, there is NO co-insurance (80/20 or
70/30). The plan pays 100% of ALL healthcare expenses, up to the maximum.
This plan, once it is understood is by far the best alternative to reduce overall
healthcare costs. For more about Health Savings Accounts,
go to: www.horizon2000.org/HSAFAQs.html
“Do I have to set up an HSA through an Insurance Carrier?”
NO. Many financial institutions offer them as stand-alone accounts.
BUT, leave the Health Insurance business in the hands of a capable,
licensed and reputable Insurance agent – not a banking officer.
“How much should I plan to budget for Health Insurance?”
Think about a luxury or habit you spend money for that you can eliminate or curb.
Doing without some may even be healthier. Most people can find enough there to
cover the cost of a Basic Plan. Encourage your employer to set up a Section 125
so you can Payroll Deduct. They may even offer to contribute the Payroll Tax
savings toward your premium.
“Can I get a better Health Insurance deal on the web?”
It depends on what you consider a “better” deal. I encourage clients to do some
shopping around, but BE CAREFUL when you share personal information over the
phone or Internet, you could be severely compromised. Almost every company
(not Brokers) offering rate quotes over the Internet can put you in touch with a
reputable, local agent who will properly asses your needs and budget. Most
important, they will only offer the plans you may qualify for, instead of purchasing
something you may not qualify for – then having to wait indefinitely for a refund.
Application/processing fee on an Internet purchase is usually non-refundable.
Also, at some point you will need the personal services of a licensed agent.
Let them help you.
“What is C.O.B.R.A.?”
As part of the Health Insurance Privacy & Portability Act (HIPPA),
COBRA was established to guarantee temporary coverage for employees and
their dependents after certain “Qualifying” events, such as termination of
employment. It is a very expensive “Toll Bridge” intended to provide coverage
until other insurance is in effect – through a new employer Group or Individual
plan. The Carrier can legally charge up to 140% of the Group Rate. They DO. The
Carrier must be notified within 61 days of your last date of employment (eligibility)
and can be renewed for up to 18 months.
A Short Term Major Medical is a much more affordable alternative
for this temporary need.
“Does it matter If my current coverage lapses before I get
replacement coverage?”
You must still have coverage in force before you can get a “Replacement”.
Again, you have only 61 days to get full advantage for any pre-existing condition.
Otherwise, you start over with what is usually a two-year waiting period, before
benefits for a pre-existing condition are payable. NEVER let a current policy
lapse before a new policy is issued and delivered to you. Depending on your
policy renewal date, in some instances you can use your Grace Period, while
waiting for new coverage to take effect. Your agent can advise you on how to
get up to 30 days of coverage at no cost when changing carriers.
“Are Health Insurance Plans available to insure virtually anyone?”
ALMOST. Unless you have been diagnosed with a life-threatening disease or
condition, some type of insurance can be obtained.
Some people ask, “What kind of Health Insurance is the BEST?”
The correct answer is – “the kind you can qualify for and afford to pay for”.
Today, ANY Health Insurance is better than NO Health Insurance. There is a
perception among many Healthcare Providers that, if you don’t have insurance,
you’re probably a poor risk to pay their bill. Most plans will pay something, and
many providers will set up a payment schedule for the balance, and/or will
“adjust” the amount owed by at least 25% IF you have some kind of coverage.
That’s because they know you are doing your best.
Have a Question??? Comment??? Opinion???
Many of these came from my other clients and I welcome yours.
Simply visit my website at: www.horizon2000.org/INSURANCE.html
and click on the “Contact Us” email link.
Shopping for Health Insurance on your own is not
fun. You need and deserve expert advice and counsel.
Please let us know what we can do to help make your
Insurance Shopping experience as easy as it can be.
any Health Insurance solicitor.
They're not hard and they could save you money.
Here are some of the most important.
About the Company
- What is the A.M. Best Rating? This is an industry rating issued to ALL
companies, based on their Claims Paying Ability & Experience (A+ - C-) - How Long has the Company been licensed in South Carolina? Many
companies come and go, leaving their policyholders with no recourse. - Where is the Local, State or Regional office located? You may need
policyholder assistance. - What is the "Trend Factor" (%tage of Annual Rate Increase) for the
Company's State-Approved Health Insurance plans? (see Compare
Rates page)
Score: 1. A or better 2. 5 years or longer 3. In South Carolina 4. 18% or less
(20%+ doubles the premium in 5 years or less.)
About the Policy
- Is the policy "Guaranteed" or "Optionally" Renewable?* If not, for what
reason(s) may it be cancelled or non-renewed? - Is this a Comprehensive Major Medical or a Limited Hospital/Surgery
Plan? - Are premiums based on "Attained Age" or "Issue Age"? ( Attained Age
premiums typically increase more frequently than Issue Age premiums) - Are there premium "Classifications"?** (Preferred, Standard, Sub-
Standard, Tobacco User) - Is there a "Healthy Insured" Discount? (No Medications, Medical
Condition(s)/Diagnosis or Hospital Confinement within last 10 years) - What is the "Co-Insurance"*** factor for this plan? (50/50, 75/25, 80/20)
Are there any premium-saving Options? - What is the "Out-of-Pocket" or "Stop Loss" Maximum?**** Per Person
or Family? Are there any premium-saving options? - What is the Maximum Benefit payable per Cause or Occurrence?*****
- Which Benefits (if any) are NOT subject to the Deductible? (Wellness,
Accident, Prescription Card, etc.) - How long will I have to wait before a Pre-Existing Condition****** is
covered? - If my needs change, does the policy have a "Conversion" privilege? (if
not, you have to re-apply, subject to the 2-year pre-existing condition
clause) - Is this the best plan of those offered by your company or agency?
WHY?
Score: The RIGHT plan will: a) be the one you fully understand b) provide the
benefits you will need and use c) fit your budget.
* Guaranteed Renewable - plans cannot be cancelled by the Company for any
reason, other than Non-Payment of premiums.
** Premium Classification - Some Companies combine all risks. Therefore,
the premiums are higher and Benefits are more restricted.
*** Lower the Co-Insurance (at risk) factor, you'll pay a higher out-of-pocket
percentage up to the Stop Loss Maximum, but you reduce your premium cost.
**** Out-of-Pocket (OOP) - The maximum amount paid by the Insured, at the
Co-Insurance percentage. Then the plan pays 100% thereafter.
***** Benefit Maximum - Some Plans have a "Per Cause or Occurrence"
maximum. Others have a Calendar Year maximum. BOTH are different from
the Lifetime Maximum.
****** Pre-Existing - A medical condition or diagnosis for which services or
medications have been provided, prescribed or recommended - usually within
the last two (2) years.
About the Marketing Agent/Representative
- Are you a Bonded & Licensed, Resident Agent/Solicitor in SC? (If not
bonded, he/she may NOT be legally accountable for what they tell you) - Are you a FULL-TIME Agent/Representative for this company?
- Have you been licensed in SC for three years or longer? (The 1st Year
attrition rate for Agents is relatively high.) - Do you reside and/or regularly work within 50 miles of my residence?
- Do you represent more than one Company?
- Do you offer other insurance products and/or services?
- Are you willing to meet with me at my residence or place of business, if
needed or requested? - Will you personally deliver and review the policy when it is issued?
- Is the plan you recommend identical or similar to one you would
purchase to secure your family's needs?
Score: If the Agent/Representative cannot answer " YES" to SIX (6) or more of
these questions, he/she is probably more interested in their Short Term goals
than your Long Term Financial Security and Peace of Mind.
Insurance Shopping TIPS
- Avoid Tele-Marketers and Agents who encourage you to apply or
enroll over the phone or online with a vengeance.
should not be entrusted to someone you cannot see, or with whom you have
not established some level of trust and confidentiality.
- Research the Insurance Company and its credentials.
issues, fines or penalties.
Call the State Insurance Commissioner's office and ask if any consumer
complaints have been filed against the company or agent.
Ask your doctor or healthcare provider about the company. They know which
ones to avoid. Examples: "Do you accept assignment from this company?"
"Do they pay claims fairly and timely?" "Are you on one their Provider lists?
- Ask to see agent credentials (State License, ID & Bond Certificate) If
he/she is reputable, they will comply.
- DO NOT attempt to apply for coverage IF: you are pregnant, have
recently been diagnosed with a medical condition, recommended for
surgery, or plan any extended travel outside the US. COVERAGE WILL
NOT BE ISSUED.
- Answer ALL questions during the application process truthfully. DO
NOT withhold any medical/medication information.
be easily accessed by the underwriter from other Insurers and/or the Industry-
sponsored Medical Information Bureau (MIB) in Baltimore, Md. Even so, some
companies have unscrupulously issued coverage, collect your premiums, then
deny a claim, cancel your policy and keep your money on the grounds the
coverage was issued based on fraudulent information (Yours or Theirs?).
- READ the QUESTIONS and CHECK the ANSWERS if your medical
history is taken by an agent, as part of an application.
underwriter. Most reputable companies have a designated toll-free # for this.
UNFORTUNATELY, some agents have altered information, just to get paid an
"advance" to submit the application. They may not care if you get coverage or
receive any benefits from it. Should you become suspicious of this activity, "Do
the Right Thing" and call the Insurance Commissioner's office to file a report
because if he/she has done it once, they will most likely do it again. The
monetary penalties are severe, but not as serious if an insured is unknowingly
denied a claim in the future.
- DO NOT cancel your existing coverage before you receive your new
policy. Your signature on a policy delivery receipt stating your health
condition has not changed since the medical underwriting information
was submitted. However, all health insurance policies in SC have a 30-
day "Grace Period" and you may be able to avoid paying premiums for
coverage by both policies (existing & replacement) for the same month
by "suspending" your bank draft until you receive the new policy. Ask
the agent how to safely accomplish this, without jeopardizing your
present coverage.
- BE SURE the agent reviews, then gives you a signed copy of the
required "Replacement Comparison" form. You may have rights
concerning pre-existing condition(s) that, without this form become null
& void. ASK to see the Replacement form to make certain the agent has
completed it correctly. Most companies require a copy of this form to
be submitted with the application.
- IF you have been declined coverage by an insurer, BE CAREFUL what
you do next, but there are some options.
regarding a Major Medical plan. If you are declined by one insurer, chances are
good you will be declined by another.
DO NOT immediately apply for coverage with another company until you talk
with an experienced agent, licensed with one or more companies that accept
special risk applicants. He/she will review your options in detail and even help
you get the underwriting information needed to properly asses your options.
It may be recommended to simply wait 6-12 months before re-applying.
During this period, a Short Term plan may be issued to cover you for any "non"
pre-existing condition or occurrence. They are GREAT!!!
Otherwise, if you have a condition that is non life-threatening, there are several
Limited Benefit plans you may qualify for, and YES - even be covered for the
pre-existing condition(s), after a period of time.
T&T Marketing represents 2 of those Special Risk companies.
Under no circumstances will we recommend an application to either of those
companies UNLESS you can be reasonably assured of coverage.
However, if all other traditional insurance options become exhausted, you can
be guaranteed coverage as a resident of South Carolina through the State-
funded Risk Pool (SCHIP), regardless of your health. It is managed by BC/BS of
SC and the premiums are high, but you will be covered, IF you can afford it.
HEALTH INSURANCE QUOTES
from 5 Different Companies
ONLINE.
Click Here
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CustomerLogon/Default.aspx?BrokerID=8604385">
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alt="INSTANT Health Quote"></a>
Individuals and businesses purchase insurance policies to protect against monetary losses. In the event of a loss, policyholders submit claims, or requests for payment,
seeking compensation for their loss. Adjusters, appraisers, examiners, and investigators deal with those claims. They work primarily for property and casualty insurance
companies, for whom they handle a wide variety of claims alleging property damage, liability, or bodily injury. Their main role is to investigate the claims, negotiate
settlements, and authorize payments to claimants, all the while mindful not to violate the claimant’s rights under Federal and State privacy laws. They must determine
whether the customer’s insurance policy covers the loss and how much of the loss should be paid to the claimant. Although many adjusters, appraisers, examiners, and
investigators have overlapping functions and may even perform the same tasks, the insurance industry generally assigns specific roles to each of these claims workers.
Adjusters plan and schedule the work required to process a claim. They might, for example, handle the claim filed after an automobile accident or after a storm damages
a customer’s home. Adjusters investigate claims by interviewing the claimant and witnesses, consulting police and hospital records, and inspecting property damage to
determine the extent of the company’s liability. Adjusters may consult with other professionals, such as accountants, architects, construction workers, engineers, lawyers,
and physicians, who can offer a more expert evaluation of a claim. The information gathered—including photographs and statements, either written, audio, or on video
tape—is set down in a report that is then used to evaluate the associated claim. When the policyholder’s claim is legitimate, the claims adjuster negotiates with the
claimant and settles the claim. When claims are contested, adjusters will work with attorneys and expert witnesses to defend the insurer’s position.
Many companies centralize claims adjustment in a claims center, where the cost of repair is estimated and a check is issued immediately. More complex cases, usually
involving bodily injury, are referred to senior adjusters. Some adjusters work with multiple types of insurance, but most specialize in homeowner claims, business
losses, automotive damage, or workers’ compensation.
Claimants can opt not to rely on the services of their insurance company’s adjuster and may instead choose to hire a public adjuster. These workers assist clients in
preparing and presenting claims to insurance companies and in trying to negotiate a fair settlement. They perform the same services as adjusters who work directly for
companies, but they work in the best interests of the client, rather than the insurance company. Independent adjusters are also self-employed and are typically hired by
an insurance carrier on a freelance or contractual basis. Insurance companies may choose to hire independent adjusters in lieu of hiring them as regular employees.
Claims examiners within property and casualty insurance firms may have duties similar to those of an adjuster, but often their primary job is to review the claims
submitted in order to ensure that proper guidelines have been followed. They may assist adjusters with complex and complicated claims or when a disaster suddenly
greatly increases the volume of claims.
Most claims examiners work for life or health insurance companies. In health insurance companies, examiners review health-related claims to see whether costs are
reasonable given the diagnosis. Examiners use guides with information on the average period of disability, the expected treatments, and the average hospital stay for the
various ailments. Examiners check claim applications for completeness and accuracy, interview medical specialists, and consult policy files to verify the information
reported in a claim. Examiners will then either authorize the appropriate payment or refer the claim to an investigator for a more thorough review. Claims examiners
usually specialize in group or individual insurance plans and in hospital, dental, or prescription drug claims.
In life insurance, claims examiners review the causes of death, particularly in the case of an accident, because most life insurance policies pay additional benefits if a
death is accidental. Claims examiners also may review new applications for life insurance to make sure that the applicants have no serious illnesses that would make
them a high risk to insure and thus disqualify them from obtaining insurance.
Another occupation that plays an important role in the accurate settlement of claims is that of the appraiser, whose role is to estimate the cost or value of an insured item.
The majority of appraisers employed by insurance companies and independent adjusting firms are auto damage appraisers. These appraisers inspect damaged
vehicles after an accident and estimate the cost of repairs. This information is then relayed to the adjuster, who incorporates the appraisal into the settlement. Auto
damage appraisers are valued by insurance companies because they can provide an unbiased judgment of repair costs. Otherwise, the companies would have to rely
on auto mechanics’ estimates, which might be unreasonably high.
Many claims adjusters and auto damage appraisers are equipped with laptop computers from which they can download the necessary forms and files from insurance
company databases. They also may use digital cameras, which allow photographs of the damage to be sent to the company via the Internet. Many also input information
about the damage directly into their computers, where software programs produce estimates of damage on standard forms. These new technologies allow for faster and
more efficient processing of claims.
When adjusters or examiners suspect fraud, they refer the claim to an investigator. Insurance investigators in an insurance company’s special investigative unit handle
claims in which the company suspects fraudulent or criminal activity, such as arson, falsified workers’ disability claims, staged accidents, or unnecessary medical
treatments. The severity of insurance fraud cases can vary greatly, from claimants simply overstating the damage to a vehicle to complicated fraud rings responsible for
many claimants and supported by dishonest doctors, lawyers, and even insurance personnel.
Investigators usually start with a database search to obtain background information on claimants and witnesses. Investigators can access certain personal information
and identify Social Security numbers, aliases, driver’s license numbers, addresses, phone numbers, criminal records, and past claims histories to establish whether a
claimant has ever attempted insurance fraud. Then, investigators may visit claimants and witnesses to obtain a recorded statement, take photographs, and inspect
facilities, such as doctors’ offices, to determine whether the doctors have a proper license. Investigators often consult with legal counsel and can be expert witnesses in
court cases.
Often, investigators also perform surveillance work. For example, in a case involving fraudulent workers’ compensation claims, an investigator may covertly observe the
claimant for several days or even weeks. If the investigator observes the subject performing an activity that is ruled out by injuries stated in a workers’ compensation
claim, the investigator will take video or still photographs to document the activity and report it to the insurance company.