Purposely NOT claiming on insurance

by Guest » Thu Jun 19, 2008 02:50 pm
Guest

I'm currently on COBRA, and have had a few doctor's visits.

When COBRA runs out, I plan get my COBRA converted to an individual policy.

When converting from COBRA -> individual, does one have to fill out a whole health questionnaire and medical history?

If not, should I purposely hold out on claiming my recent doctor's visits, since that would lower my premiums for the individual policy?

I don't want to do anything unethical or illegal. Thanks!

Total Comments: 10

Posted: Thu Jun 19, 2008 04:39 pm Post Subject: Claim is based on incurred

It will not matter when you submit your claim. The insurance that is effective when the claim was incurred will be the responsible party. If you would try to submit it to the new carrier they would deny it. (Furthermore, changing the date on a claim to reflect the effective date of the new coverage is yes, illegal)

Why would submitting a claim at a later time reduce your premiums on an individual policy? Well let me state that more effectively. It would not. A PCE could effect an individual policy. But this is usually regulated by the state.

Short answer: submit your claim.

Posted: Thu Jun 19, 2008 07:23 pm Post Subject:

I think you misunderstood me. I do not want to lie or omit vital information on an application.

But if my insurance carrier will never give me an application, and instead base the premiums on past claims, then should I just pay for my recent doctor's visits out-of-pocket, and never even submit these claims?

Example:

Joe Smith has a COBRA policy, sees a doctor, but DOES NOT submit it as a claim. So the insurance company doesn't know about the doctor's visit. When COBRA runs out, the insurance company offers to convert to an individual policy, without asking Joe for a new application.

Jane Smith has a COBRA policy, sees a doctor, but DOES submit it as a claim. So the insurance company knows about the doctor's visit. When COBRA runs out, the insurance company offers to convert to an individual policy, without asking Jane for a new application.

My guess is that Joe has done nothing wrong, since he was under no obligation to claim his doctor's visit under COBRA, and the insurance company never asked him anything about it. My guess is further, that Jane's individual policy will have a higher premium than Joe's, since she has a history of claims.

So, my questions are:

1. How common is it for insurance companies to request a whole new application with medical history, etc on it, when converting from COBRA to an individual policy?

2. Am I right that Joe has done nothing wrong or unethical?

Thank you.

Posted: Thu Jun 19, 2008 09:54 pm Post Subject:

I'm going to submit the claims anyway. But I would still like to continue this discussion, and would greatly appreciate continuing this thread, if only for my own academic curiousity.

Please let me have more of your views!

Posted: Mon Jun 23, 2008 01:11 pm Post Subject:

When converting from COBRA -> individual, does one have to fill out a whole health questionnaire and medical history?


I think data-capturing is always there & it makes the entire process safer for you. Believe me every time you opt for a plan it is an agreement that you're signing in- & hence its a legal promise as you rightly guessed!

Posted: Tue Jun 24, 2008 09:50 am Post Subject:

Hi some0481, I think you have a very valid question. I too definitely support to continue this thread for more information. As far I know that your insurer will access to your medical history to determine your insurability. And when you're applying for an individual plan, they tend to delve more into your past records. Hence, the possibility is there that they will unearth any issue that you might have kept hushed.

Also they'll access your CLUE report to check your claiming habit. If you have made too much claims within a short period of time, the possibility is there that they might deny you a coverage. However, if you've decided not to file a claim but to pay for it out-of-pocket, it'll not get reflected in your CLUE report.

The insurers put more emphasis on the CLUE report to determine the premium rate for the individual. Hence, no report of the claim will certainly lower your premium to some extent if not the reason to visit the doctor qualifies as the pre-existing condition, which might again demand premium rate modification.

Posted: Wed Jun 25, 2008 03:21 pm Post Subject: Question

Alabama - I understand the logic. However, I don't agree that 1 basic claim will change her insurability. Obviously there are exceptions such as a catastrophic claim and others but a basic physicians office visit or some other routine exam is going to have minimal impact on her aggregate claims history.

Posted: Thu Jun 26, 2008 06:55 am Post Subject:

Alabama - I understand the logic. However, I don't agree that 1 basic claim will change her insurability.



Right, BenefitsRMyLife, unless its a serious health issue that requires constant medical assistance. However, if any way the medical reason qualifies as a pre-existing condition, the insurer will demand high premium from the applicant, though not all insurers cover the pre-existing conditions and some cover it only under certain circumstances. But a regular visit to the physician is hardy going to alter the rates for him, because there is no penalty for being a health freak :wink:

Posted: Fri Aug 15, 2008 12:57 pm Post Subject:

The fact that you pay for something out of pocket does not affect your insurability. The new insurance company, if they underwrite the policy, will ask you if you have had certain conditions or treatments. Your answer should not be dependent on whether you or an insurance company or the man on the moon paid the for the claim.

Also the new insurance company may check with your doctor to see what treatment you have had and for what conditions. Legally they can do that even if you don't put your doctor's name on your application.

You can withhold information on your application and get a policy approved. However, if they discover adverse information within the first two years, they can rescind your policy and make you pay them for any claims they have paid in your behalf. They will also refund your premiums, but your premiums may only be a fraction of the claims.

You didn't mention what condition you needed treated. Not all conditions will cause you to be denied by a new insurance company. If you had a cold, no insurance company will say no based on that. If you had a heart attack last week every company that underwrites will say no. If you had cancer 8 years ago and no treatment in the last 5 years, some will say yes and some will say no.

You should have an open and honest discussion with a reputable, knowledgeable health insurance agent who serves your area. S/he can tell you with reasonable accuracy whether or not your health history will cause you to be denied.

Posted: Tue Aug 26, 2008 08:17 am Post Subject:

If you have paid for your doctor's visits from your own pocket ,and not from your insurance policy it won't be a problem.Even if you have claimed your insurance and it's for a minor thing then that also won't be a problem I think ,and it won't lead to increase in premiums in your future plans.I don't think holding back the information regarding your claims will not do anything good as the companies are sure to find out .

Posted: Tue Aug 26, 2008 09:22 am Post Subject:

What matters the most with the health insurance company is your current health condition and depending on that it will decide to cover you.

Whether the insured has paid the doctor's fees out of pocket or has paid it through his insurer won't matter much to the insurer. What he is really interested in finding out is whether or not you are in a health condition that meets with his underwriting policy?

You mustn't face much trouble in getting insurance if you have continuous health coverage in the past months.

However, if you weren't covered in the past two months and had been treated for a pre-existing condition during the last six months, the insurer may deny the coverage on the basis of the pre-existing health condition.

~Jeremy

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