Guide to Understanding Underwriting What is underwriting? The process of selecting risks for insurance in respect of a plan and classifying members according to their degrees of insurability so that the appropriate premium may be charged and the terms offered may be reviewed. This process is performed in an insurance company by an underwriter. What could be the underwriting requirements? The process may involve the review of a Personal History Questionnaire (PHQ), a Personal Medical Attendant s Report (PMAR), a Medical Examiner s Report (MER), a full blood analysis, a laboratory urinalysis, an electrocardiogram (ECG), a chest x-ray or other specified tests as deemed necessary by the underwriter. What is the Personal History Questionnaire (PHQ)? The PHQ is the first stage of the underwriting process. It primarily reviews the age, occupation, hazardous pursuits, general habits, personal medical history and family history of members. All fields of the PHQ must be completed in full, as delay in the process will be incurred if they are not. Should the form be incomplete, Generali Worldwide will contact the member directly at the contact address indicated on the PHQ (usually e-mail) to obtain future details. The PHQ relies on an element of utmost good faith in that we assume that the member has been honest and has declared any relevant personal details accurately. Failure to do so could result in any claim being reduced or refused. It is essential that the consent form on the PHQ is signed by the member to enable us to seek further medical evidence, if required. Please note an unsigned PHQ would be considered invalid. A PHQ is valid for 90 days from the date it is signed by the member. Therefore, failure to obtain all necessary additional medical information within that period would result in the member having to complete a new PHQ. Alternatively the member may sign a Declaration of Continued Good Health to indicate that there has been no change in their health since they first signed the PHQ.
What is a Personal Medical Attendant s Report (PMAR)? After review of the PHQ, our underwriter may request the completion of a PMAR. This report is commonly known as an APS (Attending Physicians Statement) in the USA. This is a relatively short report that is completed by the applicant s regular medical practitioner based on their medical history. It is often used to clarify an issue declared on the PHQ or to confirm past medical history. The PMAR is requested through Generali Worldwide or our medical agents and sent directly to the doctor identified on the PHQ. The doctor completes the form, using their records of the member s medical history and returns it via our medical agents. What happens if the member s doctor does not respond? Where the member s doctor is not responding to our requests and reminders, we may contact the member directly so they may stress to their doctor first hand the importance of our request. What happens if the member has no regular doctor? In the event that the member has indicated on their PHQ that they do not have a regular doctor, we may request that the member attends a basic medical examination. This would be organised through our medical agents. What is a Medical Examiner s Report (MER)? The MER in an independent medical examination, which provides details of the applicant s current state of health. Our medical agents arrange for the member to undertake an examination, which might include laboratory tests, with a Generali Worldwide approved doctor (not the member s own doctor). How is the MER arranged? The member is contacted directly by our medical agents at the contact details provided on the PHQ and advised of the name of the doctor and details of the surgery in order for them to make an appointment. For the member s convenience our medical agents may ask the member to provide the name of a clinic or hospital closer to their work where the examination and/or laboratory tests can be completed.
Our medical agents will deal directly with the member throughout this process and the employer will not be involved. How long does it take to get the results? Once the member has attended the MER, Generali Worldwide should receive the results between 4 and 6 weeks, although the exact period depends on the location and availability of facilities. The results of the MER will be forwarded to our medical agents who will send them to us. What if Generali Worldwide does not obtain the MER or relevant medical information? Where the member has attended the requested medical but the doctor s surgery is not providing the evidence in a timely manner, we will contact the surgery through our medical agents and keep the employer informed of our progress. It should be noted that after a period of three months the test results will no longer be valid. It is therefore imperative that they are received within that time. Should the results have expired, the member would be required to attend repeat tests in order to obtain the missing information. Where the member has not attended the requested medical? In the event that our medical agents have been unable to make contact with the member or the member has failed to undergo the arranged medical, underwriting will be suspended after a period of 120 days from the date of receipt of the PHQ or from the date of joining if no PHQ was submitted. In this case, the employer is advised in writing by our underwriter that the member s cover is restricted or declined. The member may re-engage the underwriting process by completing a new PHQ. Could Generali Worldwide use other medicals as evidence? In the event that the member attended a pre-employment medical or a medical with another insurance company, this may be used for the purposes of underwriting, subject to receiving a letter of consent from the member. Additional evidence may remain necessary at the discretion of the underwriter.
What does restricted cover mean? Depending on the policy conditions, restricted cover may mean acceptance: For accidental cover only where there is no FCL. Up to Free Cover Limit. Up to previously insured amount. With pre-existing medical condition exclusion. What is the Free Cover Limit? A Free Cover Limit (FCL) is the amount of cover that is provided on a plan to all eligible employees (members) without the requirement for any medical evidence. In the event that a member s cover exceeds this level, underwriting will apply to the amount of cover above the FCL. If the member s benefits are below the FCL, they will not be subject to underwriting provided that the member fulfils the eligibility conditions. The FCL is set at plan inception and is usually available for plans above a certain membership size. It can be reviewed at renewal should the membership or the benefits offered have changed. Please contact your Account Executive for further details. What are the possible underwriting decisions? After review of evidence, one of the following decisions will be made: Acceptance on standard terms the member is accepted for full benefits and the premium rates are the applicable policy rates. Acceptance with an exclusion the member is accepted for full benefits for any condition apart from the condition(s) detailed in the exclusion and the premium rates are the applicable policy rates. Acceptance with pre-existing medical exclusion the member is accepted at standard terms but, in this case, no benefit will be payable if the claim is as a result of any medical or related condition for which symptoms have appeared and which were first diagnosed, treated, advice sought or known to be in existence prior to the completion of the PHQ. This exclusion will be removed once the member has not sought any further advice, treatment or suffered any symptoms for a two year period from the date of acceptance. Acceptance with a medical loading the member is accepted for full benefits and an additional percentage increase would be charged on top of the applicable policy rates.
Acceptance on no worse terms basis - the member is accepted for full benefits apart from any previous exclusion or condition that may have been imposed on the member s coverage by a previous insurer. Postponed the member s cover is restricted for the time being and will be reviewed at a later date. This decision may be applied if the member has recently begun treatment for a condition which is under review. The underwriting will be carried out again when the member s condition has improved and treatment is terminated or under control. Declined based upon the evidence received, no cover will be provided for this member and no premium will be payable from the date of the decision. If there is a Free Cover Limit under the policy, the member is accepted up to the FCL and premium is payable for cover up to this benefit level. What if the member disagrees with the underwriting decision? Should the member wish to seek clarification regarding their underwriting decision, they should write to the Chief Medical Underwriter at CMO@generaliguernsey.com or PO Box 613, Generali House, Hirzel Street, St. Peter Port, Guernsey GY1 4PA, Channel Islands. Correspondence will be directly between the member concerned and the Chief Medical Underwriter and will not involve the employer in any way. Any response which involves medical information will be provided to the member s doctor as disclosed on the PHQ and not directly to the member. The member s doctor is invited to comment on the decision or provide additional information. The original underwriting decision would then be reviewed by our Chief Medical Underwriter for a final decision. Who pays for the medical underwriting costs? Bills in respect of medical underwriting will normally be paid to the surgery directly by our medical agents. In the event that a member has had to pay the medical bill, this will be reimbursed 100%. In order to obtain this refund, the member is required to send the medical invoice and receipt to our medical agents, who will arrange for reimbursement. Please note that we will only reimburse the costs of the medical tests requested by our medical agents. Any other tests or costs incurred will not be reimbursed.
How do we communicate the level of cover in place? Underwriting decisions are communicated directly to the employer by our underwriting team. In addition, we provide regular underwriting updates to the employer indicating the level of cover in place whilst underwriting is pending. The employer is responsible for advising the member concerned of their level of cover. Once acceptance terms have been confirmed, will the member need to be underwritten again? A member will need to be underwritten upon joining the plan if their benefit is above the FCL or if there is no FCL, unless members are accepted on no worse terms basis at our discretion. Once the underwriting process has been completed and acceptance terms have been confirmed, the member will not need to be underwritten again unless they have a salary increase of over 15% or if this increase brings their benefit above the FCL. The member will then seek to obtain coverage for full benefits above the previously insured amount. Confidentiality Generali Worldwide s underwriting team deals with the collection of the medical information and uses the services of contracted medical agents, who have global networks of recommended independent doctors. The medical forms (PMAR, MER etc.) are issued by our underwriter (or via our medical agents) directly to the member s medical practitioner or independent doctor and these forms should be returned to the Chief Medical Underwriter (or the medical agents if issued by them) to ensure complete confidentiality.