Medical Underwriting
Encyclopedia
Medical underwriting is an insurance
term referring to the use of medical or health status information in the evaluation of an applicant for coverage (typically for life
or health insurance
). As part of the underwriting
process, health information may be used in making two related decisions: whether to offer or deny coverage; and what premium rate to set for the policy. The use of medical underwriting may be restricted by law in certain insurance markets. Where allowed, the criteria used should be objective, clearly related to the likely cost of providing coverage, practical to administer, consistent with applicable law, and designed to protect the long-term viability of the insurance system.
To conduct medical underwriting, an insurer asks people who apply for coverage (typically people applying for individual or family coverage) about pre-existing medical conditions. In most U.S. states, insurance companies are allowed to ask questions about a person's medical history in order to decide whom to offer coverage, whom to deny and if additional charges should apply to individually purchased coverage.
While most discussions of medical underwriting in health insurance center around medical expense insurance, similar considerations apply for other forms of individually purchased health insurance, such as disability income and long-term care insurance.
, cancer
, and heart disease
, but also such common ailments as acne
, being 20 pounds over or under weight, and old sports injuries. An estimated 5 million of those without health insurance are considered "uninsurable" because of pre-existing conditions.
One large industry survey from 2004 found that roughly 13% of those who applied for individual health insurance were denied coverage after undergoing medical underwriting. Declination rates increased significantly with age, rising from 5% for individuals 18 and under to just under a third for individuals aged 60 to 64. The same study found that, among those who received offers for coverage, 76% received offers at standard rates; 22% were quoted higher rates. The frequency of increased premiums also increased with age, so for applicants over 40, roughly half were affected by medical underwriting, either in the form of denial or increased premiums. The study did not address how many applicants offered coverage at higher premiums decided to decline the policy. A study conducted by the Commonwealth Fund
in 2001 found that, among those aged 19 to 64 who sought individual health insurance during the previous three years, the majority found it unaffordable, and less than a third ended up purchasing insurance. However, this study did not distinguish between consumers who were quoted increased rates due to medical underwriting and those who qualified for standard or preferred premiums.
Measuring the percentage of applicants who were denied coverage does not capture any effect that occurs before an application is submitted. If individuals with serious health conditions never apply because they expect that they will be denied coverage, they will not show up in the declination rate. Conversely, if they apply with multiple insurers in hopes of finding one that will issue them a policy, they will be over-represented in the declination rate. The 2001 Commonwealth Fund study found that a majority of adults reported that it was at least somewhat difficult to find an affordable health insurance policy. Among adults over 30, the percentage reporting difficulty did not vary significantly by age. Those with health problems were somewhat more likely to report having difficulty obtaining affordable health insurance (77% versus 64% of those in good health).
Some American states have made medical underwriting illegal as a prerequisite for health coverage, which means if you ask for health insurance and pay for it, you get it. These states also have the highest premiums for individual health insurance.
However, in most cases an insurer's ability to "re-underwrite" an existing guaranteed renewable policy is limited by contract provisions and state law. Even so, premiums can rise significantly for existing policies if the average health of the policyholders with a particular product deteriorates. This often happens when rising premiums drive healthier individuals (who can buy another policy on favorable terms) out of the product, leaving only those who are relatively less healthy. One factor driving this is the increase in costs as individuals who initially pass underwriting develop health problems. In general, claim costs rise significantly over the first five years that an individual health insurance policy is in force.
Several solutions have been proposed for this "closed block" problem, including requiring insurers to "pre-fund" for cost increases over the lifetime of a product, provide cross-subsidies between blocks of products by pooling products across durations, provide cross-subsidies by placing limits on the allowed variation in premiums between products, or create state-sponsored risk pools for individuals trapped in a closed block. The American Academy of Actuaries
performed a study of these proposed solutions for the National Association of Insurance Commissioners
and modeled the likely impact of each. All of these solutions would increase the initial cost of a new policy and reduce cost increases over time.
, protects insurers from intentional fraud. It affects only about 1% of individual policyholders, but appears to be on the increase. Rescission practices by several large insurers have attracted media attention, class-action lawsuits, and regulatory attention in several states. In 2007, California passed legislation to tighten the rules governing rescissions. In December 2007 a California appeals court ruled that a health insurer could not rescind coverage without showing that either the policyholder willfully misrepresented his or her health or that the insurer had investigated the application before issuing coverage.
Insurance
In law and economics, insurance is a form of risk management primarily used to hedge against the risk of a contingent, uncertain loss. Insurance is defined as the equitable transfer of the risk of a loss, from one entity to another, in exchange for payment. An insurer is a company selling the...
term referring to the use of medical or health status information in the evaluation of an applicant for coverage (typically for life
Life insurance
Life insurance is a contract between an insurance policy holder and an insurer, where the insurer promises to pay a designated beneficiary a sum of money upon the death of the insured person. Depending on the contract, other events such as terminal illness or critical illness may also trigger...
or health insurance
Health insurance
Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care expenses among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is...
). As part of the underwriting
Underwriting
Underwriting refers to the process that a large financial service provider uses to assess the eligibility of a customer to receive their products . The name derives from the Lloyd's of London insurance market...
process, health information may be used in making two related decisions: whether to offer or deny coverage; and what premium rate to set for the policy. The use of medical underwriting may be restricted by law in certain insurance markets. Where allowed, the criteria used should be objective, clearly related to the likely cost of providing coverage, practical to administer, consistent with applicable law, and designed to protect the long-term viability of the insurance system.
Health insurance underwriting
Health insurance underwriting is the process that a health insurer uses to encourage potential health risks in its pool of insured people against potential costs of providing coverage.To conduct medical underwriting, an insurer asks people who apply for coverage (typically people applying for individual or family coverage) about pre-existing medical conditions. In most U.S. states, insurance companies are allowed to ask questions about a person's medical history in order to decide whom to offer coverage, whom to deny and if additional charges should apply to individually purchased coverage.
While most discussions of medical underwriting in health insurance center around medical expense insurance, similar considerations apply for other forms of individually purchased health insurance, such as disability income and long-term care insurance.
Purpose
From the insurers' point of view, medical underwriting is necessary to prevent people from purchasing health insurance coverage only when they are sick, pregnant or need medical care. This tendency is called "adverse selection," i.e., a system which attracts high utilization users while discouraging low utilizers from participating. Proponents of underwriting believe that, if given the ability to purchase coverage without regard for pre-existing medical conditions (i.e., no underwriting), people would wait to purchase health insurance until they got sick or needed medical care. Waiting to obtain health insurance coverage until one needs coverage then creates a pool of insureds with "high utilization," which then increases the premiums that insurance companies must charge in order to pay for the claims incurred. In turn, high premiums further discourage healthy people from obtaining coverage — particularly when they realize that they will be able to obtain coverage when they need medical care.Effects
Proponents of medical underwriting thus argue that it ensures that individual health insurance premiums are kept as low as possible. Critics of medical underwriting believe that it unfairly prevents people with relatively minor and treatable pre-existing conditions from obtaining health insurance. Diseases that can make an individual uninsurable include serious conditions, such as arthritisArthritis
Arthritis is a form of joint disorder that involves inflammation of one or more joints....
, cancer
Cancer
Cancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
, and heart disease
Heart disease
Heart disease, cardiac disease or cardiopathy is an umbrella term for a variety of diseases affecting the heart. , it is the leading cause of death in the United States, England, Canada and Wales, accounting for 25.4% of the total deaths in the United States.-Types:-Coronary heart disease:Coronary...
, but also such common ailments as acne
Acne
Acne is a general term used for acneiform eruptions. It is usually used as a synonym for acne vulgaris, but may also refer to:*Acne aestivalis*Acne conglobata*Acne cosmetica*Acne fulminans*Acne keloidalis nuchae*Acne mechanica...
, being 20 pounds over or under weight, and old sports injuries. An estimated 5 million of those without health insurance are considered "uninsurable" because of pre-existing conditions.
One large industry survey from 2004 found that roughly 13% of those who applied for individual health insurance were denied coverage after undergoing medical underwriting. Declination rates increased significantly with age, rising from 5% for individuals 18 and under to just under a third for individuals aged 60 to 64. The same study found that, among those who received offers for coverage, 76% received offers at standard rates; 22% were quoted higher rates. The frequency of increased premiums also increased with age, so for applicants over 40, roughly half were affected by medical underwriting, either in the form of denial or increased premiums. The study did not address how many applicants offered coverage at higher premiums decided to decline the policy. A study conducted by the Commonwealth Fund
Commonwealth Fund
The Commonwealth Fund is a private U.S. foundation whose stated purpose is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, especially for society's most vulnerable.-History:...
in 2001 found that, among those aged 19 to 64 who sought individual health insurance during the previous three years, the majority found it unaffordable, and less than a third ended up purchasing insurance. However, this study did not distinguish between consumers who were quoted increased rates due to medical underwriting and those who qualified for standard or preferred premiums.
Measuring the percentage of applicants who were denied coverage does not capture any effect that occurs before an application is submitted. If individuals with serious health conditions never apply because they expect that they will be denied coverage, they will not show up in the declination rate. Conversely, if they apply with multiple insurers in hopes of finding one that will issue them a policy, they will be over-represented in the declination rate. The 2001 Commonwealth Fund study found that a majority of adults reported that it was at least somewhat difficult to find an affordable health insurance policy. Among adults over 30, the percentage reporting difficulty did not vary significantly by age. Those with health problems were somewhat more likely to report having difficulty obtaining affordable health insurance (77% versus 64% of those in good health).
Some American states have made medical underwriting illegal as a prerequisite for health coverage, which means if you ask for health insurance and pay for it, you get it. These states also have the highest premiums for individual health insurance.
Renewals
In most states, individual health insurance policies are "guaranteed renewable," meaning that once a policy has been issued, the policyholder can keep it forever — regardless of medical conditions — as long as the required premiums are paid. There have been instances where insurers have increased premiums at annual renewals based on an individual's claim history or changes in their health status. This was possible when coverage was marketed to individuals through discretionary group trusts, escaping some states' rules governing the individual health insurance market. The insurer that was first identified by The Wall Street Journal as reunderwriting policyholders has since publicly stated it will discontinue the practice.However, in most cases an insurer's ability to "re-underwrite" an existing guaranteed renewable policy is limited by contract provisions and state law. Even so, premiums can rise significantly for existing policies if the average health of the policyholders with a particular product deteriorates. This often happens when rising premiums drive healthier individuals (who can buy another policy on favorable terms) out of the product, leaving only those who are relatively less healthy. One factor driving this is the increase in costs as individuals who initially pass underwriting develop health problems. In general, claim costs rise significantly over the first five years that an individual health insurance policy is in force.
Several solutions have been proposed for this "closed block" problem, including requiring insurers to "pre-fund" for cost increases over the lifetime of a product, provide cross-subsidies between blocks of products by pooling products across durations, provide cross-subsidies by placing limits on the allowed variation in premiums between products, or create state-sponsored risk pools for individuals trapped in a closed block. The American Academy of Actuaries
American Academy of Actuaries
The American Academy of Actuaries, also known as the “Academy” or the AAA, is the body that represents and unites United States actuaries in all practice areas...
performed a study of these proposed solutions for the National Association of Insurance Commissioners
National Association of Insurance Commissioners
The National Association of Insurance Commissioners is an Internal Revenue Code Section 501 non-profit organization which seeks to organize the regulatory and supervisory efforts of the various state insurance commissioners from around the United States. The NAIC was formed in 1871. Its current...
and modeled the likely impact of each. All of these solutions would increase the initial cost of a new policy and reduce cost increases over time.
Rescissions
Insurers have the right to cancel individually purchased insurance if the insurer finds that the applicant provided incomplete or inaccurate information on the application, thereby affecting the medical underwriting process. This practice, called rescissionRescission
In contract law, rescission has been defined as the unmaking of a contract between parties. Rescission is the unwinding of a transaction. This is done to bring the parties, as far as possible, back to the position in which they were before they entered into a contract .-In court:Rescission is an...
, protects insurers from intentional fraud. It affects only about 1% of individual policyholders, but appears to be on the increase. Rescission practices by several large insurers have attracted media attention, class-action lawsuits, and regulatory attention in several states. In 2007, California passed legislation to tighten the rules governing rescissions. In December 2007 a California appeals court ruled that a health insurer could not rescind coverage without showing that either the policyholder willfully misrepresented his or her health or that the insurer had investigated the application before issuing coverage.