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INDIVIDUAL HEALTH INSURANCE Questions & Answers

Q. When I apply for insurance, what will they ask?

A. Personal information to determine your eligibility. Companies screen applicants for individual health insurance, so you will fill out an application and answer questions on your medical history.

If your information is incomplete or inaccurate regarding health history or age, the company may deny benefits or rescind your coverage. Companies frequently ask physicians for medical records and may require you to take additional physical exams or blood tests. However, they cannot ask you for an HIV test, except for disability income and life insurance. People with anything serious in their medical background may be charged a higher price for coverage or may be unable to find individual health insurance at any price.

Q. Can I return my policy?

A. Yes. If you are accepted for individual coverage by an insurer, you have a "free look" or review period which varies from 10 to 30 days. If you decide you do not want the policy, return it by certified mail within the required period of time and request a full refund of the premium paid. Employer group health plans do not have a "free look" period.


HEALTH INSURANCE TERMS YOU SHOULD KNOW

Assignment of Benefits-When you assign benefits, you sign a paper allowing your hospital or doctor to collect your health insurance benefits directly from your health insurance company. Otherwise, you pay for the treatment and the company reimburses you.

Claim-Notification to the insurance company from the insured or health provider (if you have assigned benefits) that a payment is due under provision of the insurance policy.

Co-Payment-The portion charges paid by the patient in addition to any deductible for covered services and supplies.

Deductible-A fixed amount which is deducted from eligible expenses before benefits from the insurance company are payable. You may choose a higher deductible to lower your premium.

ERISA-Employee Retirement Income Security Act (of 1974). Administered by the U.S. Department of Labor, ERISA regulates employer-sponsored pension and insurance plans for employees.

Grace Period-a specified period immediately following premium due date, during which payment can be made to continue the policy in force with out interruption.

Guaranteed Issue-The coverage is available regardless of prior medical history. Small employers (between 3 and 50 employees) cannot be refused coverage because of the medical history of one or more employees. Some individual plans are available on a Guaranteed Issue Basis, although premiums are higher.

Limitations-Conditions or circumstances for which benefits are not payable or are limited. It is important to read the limitations, exclusions and reductions clause in your policy or certificate of insurance to determine which expenses are not covered.

Medically Necessary-Many insurance policies will pay only for treatment that is deemed "medically necessary " to restore a person's health. For instance, many policies will not cover plastic surgery for cosmetic purposes.

Pre-Existing Conditions-Any illness or health problems you had prior to obtaining insurance. Group health care policies will cover pre-existing conditions after you have been covered for up to 6 months; Individual plans up to 12 months.

Prior Qualifying Coverage-Health plan coverage that was in effect before the effective date of the current or new coverage. Both individual and group plans must credit coverage that was in effect before the start of the current coverage toward the satisfaction of the pre-existing conditions exclusions.

Usual Reasonable and Customary-The charges that a carrier determines normal for a particular medical procedure in a specific geographic area. If charges and higher than what the carrier considers normal, the carrier will not pay the full amount charged and the balance is your responsibility.

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