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W1282W (7-08) P .O. Box 3160 Omaha, Nebraska 68103-0160 Health Underwriting Gui

W1282W (7-08) P .O. Box 3160 Omaha, Nebraska 68103-0160 Health Underwriting Guide July 2008 06 115 3866 0708 US World Insurance Company – For Agent Use Only 2 Health Underwriting Guide W1282W (7-08) For those conditions noted by “ER or Rating%”, you have the option of choosing preference and noting on application for underwriting consideration Index Introduction ................................................................................................3 Major Medical Application Checklist .......................................................4 Preferred Underwriting Guidelines ..........................................................7 Health Insurance Build Charts .................................................................8 Non-Medical Guidelines .............................................................................9 Occupations Not Eligible .........................................................................10 Declinations ...............................................................................................11 Declinable Medications .............................................................................12 Common Medications Reference .............................................................13 Medical Underwriting Guidelines ...........................................................16 Agent Information – For Agent Use Only 3 Health Underwriting Guide W1282W (7-08) For those conditions noted by “ER or Rating%”, you have the option of choosing preference and noting on application for underwriting consideration Welcome! Thank you for choosing to sell our products. We have tried to design this guide to make your job easier. It provides you with the possible decisions available for the most common medical conditions, requiring underwriting action. The purpose of the Underwriting Guide is to show the most probable course of action to be taken by the Home Ofﬁce Underwriting Department with regard to a pre-existing health condition. It is intended as a guide only. There may be occasions when additional information is available to the underwriting staff that would require an underwriting decision other than speciﬁcally outlined in this guide. For this reason, the guide should not be interpreted as a guarantee of underwriting action on any speciﬁc case. The underwriter’s discretion is the ultimate determining factor in issuance of coverage. Field Underwriting Responsibilities Good Field Underwriting by agents is essential in serving the needs of the applicant and assuring the terms of the policy are carried out in an appropriate and timely manner. It is important that the ﬁeld underwriter makes every effort to review the completeness of the application and to accurately document the answers provided by the applicant(s). (See Major Medical application checklist on Page 4.) • Coverage cannot be guaranteed at the time the application is completed. If an applicant asks when coverage becomes effective, the agent should explain that issuance is dependent upon written approval by the Home Ofﬁce underwriters. • When the agent completes an application, each question on the application needs to be speciﬁcally asked of the applicant(s) and the answers recorded as given. • It is never permissible for the writing agent to ask a general question with reference to health history and then on receiving a negative reply, answer “No” to all of the health questions on the application. • Answers to the application health questions should not be obtained from a third party. • Where an application is required to be signed by the agent, the appointed writing agent must sign the application in ink. In signing an application an agent not only shows representation as the writing agent, but also afﬁrms that he has followed the Field Underwriting Responsibilities set out by the Company. • It is not acceptable to answer questions with “dashes” or “ditto” marks. Introduction • If a mistake is made on the application, line through the error and have the applicant initial the correction. • All afﬁrmative “Yes” answers to the application health questions must be explained in detail on the application along with the name and address of the treating or consulting physician(s). Answers on the application are considered to have been given by the applicant. The Underwriters accept the given answers as being full and complete and that the answers have not been only partially recorded or edited by the writing agent. • Any special dating request for the policy should be included with the application with an explanation. Under no circumstances will a health policy be backdated. • When a child(ren) considered for coverage does not live with the applicant the health history must be veriﬁed with the custodial parent as well as from the parent applying for coverage. Please provide an accurate telephone number for the custodial parent. • Once the writing agent completes the application, the agent cannot disclose any conﬁdential information except to the Home Ofﬁce Underwriting Department. • The writing agent should advise applicants that prior health history can result in a counter offer to their application and that the policy may be issued with exclusions and/or rated premiums. This is also noted in the AGREEMENT section of the application. That section also notes the company’s right to void or rescind coverage after issue if there has been non-disclosure of material health history. Some states have different requirements for the manner in which the Company handles material health history disclosed at application time. It is the writing agent’s responsibility to become familiar with related state law or to seek guidance from the agent’s upline Manager. • The policy provisions will determine the responsibilities or liabilities of the Company. An agent cannot and must not make any representations or promises regarding claims processing or interpretation of the policy. World Insurance Company – For Agent Use Only 4 Health Underwriting Guide W1282W (7-08) For those conditions noted by “ER or Rating%”, you have the option of choosing preference and noting on application for underwriting consideration In Risk Selection, the rule of thumb to go by is that we vastly prefer too much information to too little. With that thought in mind, here are some things you can do to help expedite your applications through the underwriting process. 1. Application All questions answered completely Complete details provided for all YES questions If quoted preferred rate, submit a completed Preferred Rating Questionnaire with application. Provide complete name, address and phone number for each doctor listed on the application, including the date of last visit, reason for visit and the results. Provide most recent blood pressure and cholesterol readings, if known. Provide all possible phone numbers where applicants can be reached for the interview and the best time for the interviewer to call. Any changes or alterations made on the application must be initialed by the applicant. All signatures and dates obtained from both the applicant and agent including those required on the HIPAA authorization 2. Forms All state speciﬁc required forms completed and signed by agent and applicant Provide all necessary information for list bill cases. Method of payment information completed and all forms needed are attached Major Medical Application Checklist Agent Information – For Agent Use Only 5 Health Underwriting Guide W1282W (7-08) For those conditions noted by “ER or Rating%”, you have the option of choosing preference and noting on application for underwriting consideration The Underwriting Process During the underwriting process, the underwriter evaluates each individual’s medical history and takes appropriate action based on the severity and prognosis of the condition(s). To expedite the underwriting process the enrollment application should be completed accurately and all medical disclosures should include the speciﬁc diagnosis, dates of treatment, medications prescribed and the results of treatment. Underwriting outcome will also vary in accordance with state requirements. In an effort to provide better up-front risk selection, an underwriter may request medical records or a paramedical exam on an applicant. This will enable us to determine at the time of application, if the applicant has a pre-existing condition or any other medical condition that will require exclusions and/or rated premium. Medical Records/ Attending Physician Statement/ Paramedical Exams The underwriter will initiate the request for medical records and exams when applicable. These requirements may be requested for conditions noted as “IC”, when no prior coverage has been in force or at underwriters discretion. We will handle costs associated for obtaining these requests up to a predetermined amount. You will be notiﬁed of this request through the application status on the website. MIB/Rx Proﬁle may be obtained as determined by Underwriting Department. Driving Records Driving records may be obtained as determined by the underwriter. Telephone Interview We use an interview Process to conﬁrm the health information contained on an application. An interviewer may attempt to contact an applicant by phone within 24-48 hours of when the application is received at the home ofﬁce. The call will take approximately 10 to 20 minutes per applicant. The interviewer will conﬁrm the accuracy of the application, obtain any additional details that are needed and clarify any incomplete information. Important: Make sure you explain this process to your client and provide a copy of the application for your client to refer to during the veriﬁcation call. Tobacco Use An applicant must not have used tobacco in any form within one year of the application date to qualify for Non-Tobacco User Rates. A certiﬁcate/policy issued with Tobacco User rates will not be considered for modiﬁcation to Non-Tobacco User rates until the insured has gone one year without using any form of tobacco, or six months have elapsed from the certiﬁcate/policy effective date, whichever is longer. In other words, a certiﬁcate/policy issued with tobacco user rates must be in force at least six months uploads/Finance/ underwriting-guide.pdf