New Business and Underwriting Guide Individual Health & Dental Insurance

Transcription

1 New Business and Underwriting Guide Individual Health & Dental Insurance September 2010

2 General Language Applicants must be able to understand English and/or French. Eligibility Applicants must have Government Health Insurance Plan (GHIP) coverage and must be a permanent Canadian resident to be eligible for any Extended Health and Dental Plan. No GHIP? Use Visitors to Canada Emergency Medical Travel Insurance until GHIP is in place. 2

3 Health and Dental Plans Flexcare DentalPlus Basic 1 DentalPlus Enhanced 1 DrugPlus Basic DrugPlus Enhanced ComboPlus Starter 1 ComboPlus Basic ComboPlus Enhanced Add-on coverage available 2 Stand alone coverage available 2 Use Flexcare Snapshots for specific coverage details for each province. Want no medical underwriting? Offer a dental plan or ComboPlus Starter. 1 These plans are Guaranteed Issue Plans not requiring any medical underwriting. 2 Extended Health Care (EHC), Hospital and Catastrophic Coverage require medical underwriting. Flexcare Select Extended Health Care (EHC) Vision Care Hospital Cash 3 Fracture Benefits 3 Travel Coverage 3 Accidental Death and Dismemberment 3 Flexcare Select is guaranteed issue Extended Health Care and Vision Care coverage plus the choice of two additional coverages. 3 In addition to EHC and Vision Care coverage, choice of any two of these coverage options. FollowMe Health Basic 4 FollowMe Health plans DO NOT require medical underwriting. Enhanced Plus 4 Unsure which FollowMe Enhanced 4 Premiere 4 Health plan is right? Offer Premiere for maximum 4 These plans are Guaranteed Issue Plans not requiring any medical underwriting, coverage can always if application is received within 60 days of termination from a group benefit plan. choose to downgrade at renewal (but would need to be medically underwritten for upgrade). The Association Health and Dental Plan Base Plan (Health & Dental) 5 Base Dental Plan 5 Bronze Plan (Health & Dental) Bronze Dental Plan 5 Silver Plan (Health & Dental) Silver Dental Plan 5 Gold Plan (Health & Dental) Gold Dental Plan 5 5 These plans are Guaranteed Issue Plans not requiring any medical underwriting. The Association Health and Dental Plan is a great individual alternative to group insurance for members of both small and large associations. 3

4 Completing an Application Information to Have Handy 1. The Government Health Insurance Plan (GHIP) numbers of everyone applying for coverage. 2. Doctor s name, address, last consultation date and information (for each applicant). 3. Names of all prescription drugs and the condition for which they are being taken. 4. Credit card information or bank information for a pre-authorized payment plan. 5. If the applicant recently had group insurance, the name of the insurer, the group plan and subscriber ID numbers, and the dates the benefits end(ed). 6. Driver s license information (if applying for Catastrophic coverage). For Fast Processing 1. Make sure ALL questions are answered. Being prepared saves application completion time. Family coverage? Each applicant is assessed separately with a different decision possible for each applicant. 2. Provide full details for all Yes answers. Use Quote and Apply online to save courier costs & 3. Complete the Practitioner and Medication sections (for each applicant). submission time. 4. Get the applicant and co-applicant(s) signatures. 5. Current date the application. 6. If faxing the application, make sure all information (including authorizations) is legible. Completing the Medical Questions It is very important that full and complete medical information is provided during the application process, so that the underwriters will be able to make a well informed decision on the application. Medical condition not addressed on application? Be sure to let us know. Application Disclosure Any injury that occurred or any medical condition, the signs of which first appeared on or before the date of the application, may not be covered by the policy. Failure to disclose such information could result in the denial of a claim and/or the cancellation or modification of the policy. Manulife Financial reserves the right to recover any claims paid due to failure to disclose any injury or medical condition that existed on or before the date of this application. Underwriting cannot ignore adverse medical history or possible risks uncovered, but not indicated on the application. Details on adverse decisions can only be shared with the applicant s doctor. Beneficiary In order to expedite the application process, the beneficiary designation under the policy will automatically default to the Estate. Following approval of the application, the policy will be issued together with a change of beneficiary designation form. The policyholder must complete, sign and return this form to Manulife Financial in order to ensure that a specific individual is designated to receive any proceeds payable under the policy in the event of death. Choosing Payment Options If paying by Pre-Authorized Debit, there is a 2 % discount for premiums paid upfront for a period of 6 months and 4 % for annual premium payments. There is no discount for monthly pre-authorized debit. Discounts are not available for the Credit Card payment option. Pay by Pre-Authorized Debit and save: 4% annual and 2% semi-annual payments. 4

5 Policy Issue and Premium Draw Dates Premiums for all Guaranteed Issue plans, including Flexcare Select, ComboPlus Starter, Dental Plus Basic, DentalPlus Enhanced and FollowMe Health, are in effect the first of the month following receipt of the application by Manulife Financial. Premiums for 2 months will be withdrawn at issue, and further premium payments will be debited on the first day of the month, either monthly or semi-annually, as chosen. ComboPlus Basic, ComboPlus Enhanced, DrugPlus Basic, DrugPlus Enhanced, Hospital Basic, Hospital Enhanced, Catastrophic Coverage and Extended Health Care are medically underwritten plans. The application will be reviewed by our underwriters and it will take approximately 4 to 6 weeks to complete the assessment. When approved, premiums for 2 months will be processed and the plan will come into effect on the first of the month following approval. Counter Offers In the event that the applicant is conditionally approved, a counter offer will be sent detailing the exclusions and restrictions. Following the receipt of the client s acceptance of the counter offer, premiums for 2 months will be withdrawn from the payment account. Subsequent premium payments will be debited on the first day of the month, either monthly or semi-annually, as chosen. Premiums are not reduced if exclusions or restrictions apply as full benefits are payable for all nonexcluded conditions. Health Claims Audit A Health Clains Audit involves our Claims and Underwriting areas, as well as, your client and can occur within the first two years of the policy effective date when a claim is presented, but only applies to underwritten plans. You will be notified of the audit, but the policyholder is contacted directly for a post underwriting review to determine if there was an undisclosed pre existing condition at time of application. The claim is then paid once it has been confirmed that there are no issues. If undisclosed information is uncovered, we will modify coverage or rescind the contract if necessary. 5

6 Underwriting Requirements Questions and Answers Does an applicant have to undergo a medical exam or test in order to qualify? No. The applicant will not be asked to undergo any medical exam or test. The underwriter may, however, request a medical report from the applicant s doctor. How will Manulife contact an applicant if more information is needed? If the applicant has applied through an advisor, all written requests for additional information will be sent by to the advisor s office. Applicants who apply to us directly may be contacted by phone (by the underwriter or an external provider), or letter. Does underwritten coverage cover pre-existing medical conditions? Generally, no. Provided the applicant is insurable, the underwriter may offer modified coverage with an exclusion for the pre-existing condition. Only pre-existing health conditions that are pertinent or material to the risk are excluded and usually no more than 3 exclusions are offered. The underwriter may also charge a substandard premium rating, if an exclusion alone does not sufficiently cover the risk. We always obtain agreement from the applicant before issuing coverage on a modified basis. We never do blood, urine or Paramedical Exams. Questionnaires and doctor s reports may be requested. We underwrite up front to avoid claim issues later! Let your client know what to expect: There may be other underwriting They may be declined for coverage They may be offered different coverage than what they applied for. If an applicant is currently undergoing medical testing and the results are not yet available, can they obtain coverage? No. Applicants are ineligible for coverage until all pending medical testing and investigations are completed and the results are available. Can a parent buy dependent coverage without applying for coverage for themselves or their spouses? No. At least one parent must be covered in order to insure a dependent. Can a newborn be added to active dependent coverage without underwriting? Yes. Newborns may be added to active dependent coverage, provided a written request is submitted within 30 days of the baby s birth. Requests submitted after 30 days or requests to add dependent coverage are subject to underwriting approval. An applicant is currently covered under a Manulife health plan but has reached the annual plan maximum. Should they cancel their current coverage and apply for a different plan with a higher maximum? No. The different plan would be subject to underwriting approval and previously covered conditions might be excluded under the new contract. In addition, the new coverage might be declined or offered with a substandard rating. A policyholder wants to downgrade benefits. How do they do this? A policyholder may apply to downgrade benefits by sending a signed and dated request letter. Their coverage must be in force for at least 12 months before we will agree to downgrade coverage. A change to downgrade coverage is not subject to underwriting. Policies must be inforce 12 months before policy changes. Upgrades are subject to underwriting. Note: If the policyholder subsequently wants to upgrade their coverage, they will have to re-qualify for the upgraded benefits by completing a new application. A change to upgrade coverage is subject to underwriting approval. 6

7 Can a policyholder cancel coverage and re-apply later? Yes. However, there is a 24 month waiting period before a new application can be submitted and approval will be subject to underwriting. What options are available if an applicant is declined? If an applicant is declined or does not wish to accept modified coverage, they will be offered a choice of one of our guaranteed issue products. In addition, applicants who apply for underwritten coverage within 60 days of losing their group coverage are eligible to purchase non-underwritten FollowMe Health coverage. Depending on the medical condition, we may be able to reconsider a declined applicant at a later date, provided their health condition has improved or stabilized. A fully completed application is always required for reconsideration and approval is subject to underwriting. Note: not all declined applicants can be reconsidered. Refer to the attached list of Ineligible Conditions. Our goal is to offer standard issue. We may place exclusions when required. We will make a counter offer of a guaranteed issue plan automatically for declined cases if possible. If an individual s group health coverage is terminating, can they obtain Manulife health coverage without underwriting? Yes, provided they apply within 60 days of losing their group insurance benefits. Our FollowMe Health product is available and is not subject to medical underwriting. FollowMe Health is a guaranteed issue plan if applied for within 60 days of leaving a group plan. Under the FollowMe Health plan, is coverage from a group plan uninterrupted when the FollowMe Health plan takes effect? The benefits under the previous group coverage and the FollowMe Health plan may not be entirely the same. In particular, a customer who has ongoing major dental work on his group plan may expect uninterrupted services on the FollowMe Health plan. However, only the FollowMe Health Premiere plan covers major dental work after a waiting period of 24 months. 7

8 Ineligible Conditions Important Notes: i. These ineligible conditions apply only to underwritten Health and Dental applications ii. The list is not complete, but covers some of the more commonly seen conditions or concerns. Other conditions or risk factors not listed here may also be ineligible iii. Individual consideration (IC) will be given only if the stated criteria are met. The applicant must be fully recovered and no longer receiving preventative or clinical treatment iv. For individual consideration, the applicant must provide Manulife with copies of any medical records or tests required to complete the underwriting assessment and must also assume the cost Medical Condition or Concern Decision Individual Consideration (IC) Period and/or Requirements Acromegaly Decline if unoperated, or if below IC 3-year stability period post surgery (tumour removal) Addison s Disease Decline if below IC 3-year stability period Adrenal Hyperplasia 6-month post surgery period AIDS/HIV Alcohol Abuse 5-year full recovery period + total abstinence Alzheimer s Disease Amnesia - if cause is not traumatic If cause is traumatic + return of normal cognitive functions Amyotrophic Lateral Sclerosis (ALS) /Lou Gehrig s Disease Aneurysm, Aortic or Carotid Aneurysm, Cerebral 1-year full recovery period from surgery Angina/Angina Pectoris Angioplasty Ankylosing Spondylitis, if If other than severe severe Anorexia Nervosa 5-year full recovery period + post-adolescence Aortic Stenosis - if If mild moderate to severe Aplastic Anemia Arteriosclerosis (ASVD) Ascites Bipolar Affective Disorder/Manic Depression Brain Disorder Brain Injury 1-year recovery from injury + depending on residuals Bulimia 5-year full recovery period + post-adolescence Cancer (See IC for some skin cancers) 10-year full recovery period N.B. Underwrite Skin cancers except Melanomas 8

9 Medical Condition or Concern Decision Individual Consideration (IC) Period and/or Requirements Cardiomyopathy 1-year full recovery period + only if cause is viral Cerebral Atrophy Cerebral Palsy - if If mild or if at older ages moderate to severe Decline if at younger ages Cerebral Vascular Accident (CVA)/Stroke Charcot-Marie Tooth Syndrome Chronic Obstructive Pulmonary Disease (COPD)/Chronic Obstructive Lung Disease (COLD) Heavy Cigarette Smoking, (Over 50 per day cigarette usage or equivalent of any other tobacco products) Cirrhosis Claudication Congestive Heart Failure Connective Tissue Disease Coronary Artery Bypass (CABG) Coronary Artery Disease (CAD) Crohn s Disease CREST Syndrome Cushing s Syndrome 1-year post surgery period + if stable Cystic Fibrosis Dementia Diabetes, Insulin Dependent (IDDM)/ Type 1 Diabetes Down s Syndrome if If Mild + post adolescence moderate to severe Decline if below IC Drug Abuse 5-year full recovery period Dwarfism Decline up to adolescence Post adolescence + no associated impairments Emphysema Encephalitis if cause is other than viral 1-year full recovery period + if cause is viral Fibromyalgia/Fibrositis Gaucher s Disease Gender Identity Crisis Giantism period 3-year stability period post surgery (tumour removal) Glomerulonephritis 1-year full recovery period Guillan Barre Syndrome 3-year full recovery period Heart Attack/Myocardial Infarction Hemiplegia Hemochromatosis/Bronzed Diabetes Hemophilia Hepatitis B 2-year full recovery period Hepatitis C Hepatitis Carrier 9

10 Medical Condition or Concern Decision Individual Consideration (IC) Period and/or Requirements HIV/AIDS Hodgkin s Disease 10-year full recovery period Huntington s Chorea Hydrocephalus Decline if untreated & depending on residuals 1-year recovery from surgery + depending on residuals Investigations or Tests Ongoing, Awaiting Test Results/Diagnosis Kidney, 1 previously removed Kidney Disease, Kidney Failure Leukemia Lou Gehrig s Disease (ALS) Lung, 1 previously removed Lupus, SLE Lyme Disease Lymphomas Decline Consider after final diagnosis has been made - if smoker or other co-morbid factors, or if cause is other than traumatic Apply after final diagnosis or tests completed (with results) 10-year full recovery period If cause is traumatic + no comorbid factors 1-year full recovery period 10-year full recovery period Manic Depression/Bipolar Affective Disorder Major Depression Decline if below IC 2-year stability period + postadolescence + no suicidal attempt or ideation Marfan s Syndrome Memory Loss/Memory Deficit Disorder Multiple Sclerosis (MS) Muscular Dystrophy Myalgic Encephalomyelitis Myasthenia Gravis Myocardial Infarction/Heart Attack Nephrotic Syndrome Neurofibromatosis, Multiple Dependant on Type Obesity Pacemaker (Artificial) Palindromic Arthritis Pancreatitis Paraplegia Parkinson s Disease Pemphigus Peripheral Vascular Disease Pick s Disease Polycystic Kidney Disease Polycystic Ovarian Syndrome Polycythemia Polymyalgia Rheumatica Polymyositis Pre-Mature Birth with Complications Pulmonary Fibrosis Psoriatic Arthritis Quadriplegia Renal Artery Stenosis - if cause is other than traumatic if morbid obesity, or severely overweight with co-morbid risk factors - if moderate to severe Decline - if below IC Decline if below IC If cause is traumatic Underwrite all others 2-year full recovery period If mild + 5-year stability period with use of appropriate medication 2-year full recovery period 10

11 Medical Condition or Concern Decision Individual Consideration (IC) Period and/or Requirements Rheumatoid Arthritis Sarcoidosis Schizophrenia Scleroderma (Systemic) Sclerosing Cholangitis Senile Dementia Sex Change Decline if below IC 2-year post surgery period + no residual issues Sickle Cell Disease Spina Bifida Decline - depending on severity & Depending on severity & residuals residuals [N.B. GENERALLY DECLINED] Spinal Cord Disorder/Spinal Cord Injury Stroke Due to Vascular Disease - if due to vascular disease If other than cardiovascular cause +2-year full recovery period Decline if below IC Suicide Attempt Decline if below IC 5-year full recovery period + Depending on cause & health status + post adolescence Surgery Pending or Scheduled Decline Consider after surgery & Depending on type of surgery recovery Tetralogy of Fallot Thalassemia Major Transient Ischemic Attack (TIA)/Mini Stroke Transplant (Major Organs, e.g. - if If donor + no other risk factors lung or kidney) recipient Tuberculosis 6-month full recovery period after treatment is completed Wilson s Disease 11

12 Individual Health & Dental Underwriting Build Table Important Notes: i. This table applies only to underwritten Health & Dental insurance applications. ii. Underweight applicants are assessed on an individual basis. If insurable, a substandard premium rating may be applied. iii. Applicants whose weight exceeds the MAXIMUM STANDARD WEIGHT may be offered coverage with a substandard premium. iv. Applicants whose weight exceeds the MAXIMUM SUBSTANDARD WEIGHT will be declined. v. Other medical risk factors may warrant an exclusion, rating or decline. vi. Height and weight for children are assessed on an individual basis. For ½ inches, round up to the nearest inch - Example: 5 6 ½ = 5 7 For ½ pounds, round up to the nearest pound - Example 177 ½ lbs = 178 For centimeters between bands, round up to next higher band HEIGHT MAXIMUM STANDARD WEIGHT MAXIMUM SUBSTANDARD WEIGHT HEIGHT MAXIMUM STANDARD WEIGHT MAXIMUM SUBSTANDAR D WEIGHT Feet & Pounds Pounds Centimetres Kilograms Kilograms Inches 4'9" '10" '11" ' '6" '7" Manulife reserves the right to change the above table 12