Health Insurance?

C. Steven Tucker | Mar 24, 2009 | Reply

I have been a multi state licensed health and life insurance broker for 13 years now. One of the biggest challenges I have had to deal with through the years has been trying to help the uninsurable. Unfortunately in most states if you have one of a host of “pre-existing” medical conditions you are labeled as uninsurable on an individual health insurance policy. In most states this uninsurable status lasts for many years and sometimes for life depending on the specific pre existing condition you have been diagnosed with. Some of the pre existing medical conditions that render an applicant uninsurable for ten years or more are: Heart Attack, Stroke, Diabetes, Cancer, Lupus, Multiple Sclerosis, Muscular Dystrophy, Degenerative Arthritis and a host of other pre existing conditions. In addition, there are applicants who have a combination of controlled pre existing conditions but because they have more than three “ratable conditions” they are labeled uninsurable. For example, with many carriers an applicant who has Hypertension & Hyperlipidimia but is also overweight falls under the “3 strikes your out” rule and is labeled uninsurable. Or an applicant may have two of the aforementioned controlled conditions and is not overweight but is a smoker and is then labeled uninsurable also. Or an applicant who has asthma but also smokes falls in to the same uninsurable category with many carriers.

These are just a few examples of conditions or “combo conditions” that can render an applicant uninsurable. The question then becomes, what do I do now? Who will insure me against the catastrophic medical bills that I may face in the future? Who will help me pay for the medications I currently am taking to control the aforementioned conditions? For many years depending on the state you live in you only had two options. They are as follows:

1.) If you have a corporate tax i.d. number you can purchase a small group health insurance policy from most insurance carriers. With this scenario a minimum of two people (often husband & wife) who work for the same corporation can apply for a small group health insurance policy. After a period of time, or in some cases immediately (depending on how many months you have had prior health insurance coverage without a lapse) pre-existing conditions will be covered provided that they are a covered expense on the policy.

2.) Enroll in your states insurance risk pool (if your state is fortunate enough to have one). In our home state of Illinois the risk pool is called the Illinois Comprehensive Health Insurance Plan (ICHIP). ICHIP is a state health benefits program and not an insurance company. Persons must qualify for coverage but in most cases if the applicant is coming off an exhausted qualified COBRA continuation plan from a prior employer sponsored group, their pre existing conditions will be covered from day one (provided again that those conditions are a covered expense on the ICHIP policy). However, ICHIP (and all insurance risk pools) are by no means entitlement programs. They are far from free! Premiums charged are established by law at from 125%-150% above the average rates charged individuals for comparable major medical coverage by five or more of the largest insurance companies in the individual health insurance market in that state. Suffice it to say, the premiums are far from affordable for many people. The rates for a person 50 years of age living in Chicago can range from $554 monthly for a $5,200 deductible plan to $852 monthly for a $500 deductible plan. For those who do not have an insurance risk pool in their state (http://www.naschip.org/states_pools.htm) their options are then even more limited if they are labeled as uninsurable.

Whilst the two aforementioned options should still be pursued first (if available & affordable) there is now another option. American Medical & Life Insurance Company of New York, New York is now offering Defined Benefit Health Insurance Policies to the uninsurable. There are only three restrictions to obtaining these quality Defined Benefit Health Insurance Policies. They are as follows:

1.) You may not be a Medicare recipient.
2.) You may not be receiving disability benefits.
3.) You may not be receiving workers’ compensation benefits.

There are no other underwriting requirements. This means that regardless of your pre existing condition American Medical & Life insurance company will issue you a Defined Benefit Health Insurance policy.

What exactly is covered by their Defined Benefit Health Insurance policies? Much more coverage than any other “Defined Benefit” health insurance plan on the market today. There are four different Defined Benefit Health Insurance Policies to choose from. I will list the benefits covered on the best of the four different plan options. They are as follows:

All benefits are provided on a “first dollar” basis (no deductible or co pays required)
$1,000 per day covered for the first 100 days of hospital admission
$2,000 in additional coverage for the first day of hospital admission
$1,000 in additional coverage for the first 15 days of Intensive Care or Critical Care
Unlimited inpatient our outpatient Surgical Benefit provided on all plans
One Preventative Care Visit is covered per insured per calendar year with a $150 allowance for that visit
Up to 7 outpatient doctor office visits included with the with no co pay or deductible required
Mail order Generic & Brand name medications are discounted at up to 50%
Medically necessary diagnostic tests and x-rays performed in a doctor’s office or outpatient facility (e.g. MRI, CAT Scan, EKG, Mammography)are covered up to $400 per visit with a 5 visit allowance per year
There is a 12 month waiting period for Pre Existing conditions. However, because the plan is HIPAA compliant this waiting period will be waived if you have a Certificate of Creditable coverage from another health insurance plan showing 18 months of prior coverage with no lapse of more than 63 days
$5,000 of Critical Illness coverage provided for Primary Insured & Spouse (optional on other 3 plans)
Nationwide P.P.O. network (www.multiplan.com)

Arguably these benefits rival the “first dollar” benefits provided on most major medical health insurance policies on the market today. The most attractive part about this kind of health insurance policy is that the premium required is well below half the premium required for the ICHIP state insurance risk pool. Also like the state insurance risk pool coverage these Defined Benefit Health Insurance policies are fully HIPAA compliant. This means that if you are coming off of an employer sponsored Cobra continuation plan and can produce a certificate of creditable coverage from this prior carrier showing 18 months of prior coverage with no lapse of more than 63 days your pre existing conditions will be covered from day one. If not, there is a 12 month waiting period for pre existing conditions.

Whilst a major medical health insurance policy is always the best way to insure oneself against the catastrophic medical bills one can experience throughout their lifetime, a Defined Benefit health insurance policy is most certainly a cost effective way to protect oneself if you are rendered uninsurable on the individual health insurance market and can not afford your state’s insurance risk pool coverage or can not form or afford a Small Group Health Insurance policy.

Without a doubt, this is the finest Defined Benefit health insurance policy on the market today. Most especially since the majority of other offers to the uninsurable consist of discount P.P.O. network memberships that are by no means health insurance policies. We’ve all seen them advertised from company’s like “Care Entree” or “Ameriplan” that offer “health coverage” (clever way to circumvent the words “health insurance”) that will “cover” the entire family for $89 monthly! Beware of these kinds of “discount” products! Read more about them in the September 23rd 2008 Issue of The Tennessean Newspaper

These kinds of discount “coverage” plans are so inexpensive because they provide nothing more than a P.P.O. repricing discount. This in itself is not a bad thing. However without a Major Medical or Defined Benefit health insurance policy in place one can experience catastrophic medical bills with these types of “health coverage” plans. This is the case because the average P.P.O. discount on medical procedures performed within a P.P.O. network is between 25% & 40%. For a $100 doctor office visit, this is a good deal. However, if the medical bill is $500,000 that can leave the “covered” person with as much as $200,000 in out of pocket expenses!

For more information about Guarantee Issue Defined Benefit Health Insurance Plans and or Major Medical Health insurance plans please visit click here: http://www.sbisvcs.com/guarantee_issue.htm