General & Medical Guide to Underwriting Terms
This booklet, like others in our information book series is designed to help you understand the various aspects of General & Medical private healthcare schemes and must be read in conjunction with your policy documents (part 1 and 2)
Underwriting explained 2 Types of Underwriting 4 Duty to Disclose 4 Ongoing Duty to Disclose 4 Underwriting Terms 5 Full Medical Underwriting 5 Moratorium Underwriting 5 Continued Moratorium 6 Continued Personal Medical Exclusions (CPME) 6 Medical History Disregarded (MHD) 7 Adding a baby to cover on a Medical History Disregarded Scheme 9 Transferring a scheme on a no worse terms basis Continuation of cover for Corporate Scheme leavers 10 General & Medical Finance Ltd 2012. No part of this document may be reproduced without the express written permission of General & Medical Finance Ltd
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Whenever you buy Insurance you will usually find the terms underwriting and underwritten by somewhere on the documentation. This leaflet will help you understand what General & Medical mean by these terms and how they affect your cover. The term Underwritten by is often used as an alternative term to Insurer and may be used in the policy documents or Key Facts to advise you who is accepting the risk by insuring you. In other words who is responsible for paying an eligible claim should a policy holder need to make a claim under the terms of their cover. For example in our Key Facts for Private Medical Insurance, General & Medical Insurance Ltd is shown as the insurer, because our private medical insurance policies are underwritten by General & Medical Insurance Ltd. Underwriting a new application for cover is an overall term used to describe what general (and any special) terms and conditions may be applied to the application. With Private Medical Insurance there are a number of different terms and conditions that an insurer may apply to an application so most of the terms and conditions have been grouped into distinct categories of underwriting to make it easier for the client to understand how their application is being dealt with by the insurer. When you apply for Private Medical Insurance cover with General & Medical, your application is considered by an underwriter who is based in the General & Medical Insurance Ltd office in Guernsey. The underwriter will assess from the information on your application how the application should be underwritten. For example: whether it falls, within one of the main categories and whether any special conditions, restrictions or exclusions should apply. Once the underwriter has decided to accept the application a full set of documents are sent to the applicant explaining the full details of cover available.
The main categories of underwriting for private medical insurance policies are: Full Medical Underwriting Moratorium Continued Moratorium Medical History Disregarded Continuation of Personal Medical Exclusions Each of the above is explained in detail in the following pages of this booklet. Duty to Disclose Why is it important for you to tell the truth and provide full information during application for cover? We base our decision on whether to accept an application on a number of factors. For many applications the most important thing we have to assess is the likelihood of future claims based on the current state of health of an applicant. The premiums we charge are carefully calculated to be fair to the applicant based on full disclosure. When a client makes a claim if we believe the client has withheld information about the condition at the time of application, the claim will be rejected as the applicant has disadvantaged us. Ongoing Duty to disclose Do you need to tell us of any changes after you have applied for cover? Yes you do. An applicant s circumstances may change whilst on cover which may mean the cover they have purchased is no longer suitable and they may need to change to another cover. Perhaps they may change their profession or job, perhaps they may take up hazardous sports or pastimes, perhaps they may travel abroad more frequently, or perhaps their health may change. It is always best to keep us informed as this is the best way to ensure we are able to deal with any future claims quickly and efficiently. What should you do about disclosure if you have bought cover through a broker? It is important that under the disclosure rules we, the insurer, should receive full information about the applicant at the time of application and during their time on cover. All General & Medical registered brokers under the terms of their contract with us have a duty to ensure all information disclosed to them about the applicant is passed to us. However, the applicant has a responsibility if they make disclosures to their broker to ensure the broker passes on the disclosures to us. This applies to all Full Medical Underwriting applications and Continued Personal Medical Exclusions (CPME) applications.
Full Medical Underwriting Means that we will ask for a full medical declaration for each person to be covered under the scheme. You are required to make a declaration regarding your health and tell us about any conditions which existed before joining our scheme even if a medical opinion had not been sought. Applicants must disclose relevant information. After the application form is submitted we will review the information and decide on what basis we will provide cover. We will then inform you of any pre-existing medical conditions or other medical conditions that will be excluded from cover either permanently or to be reviewed after a pre-determined period of membership. These additional exclusions will be shown on your Certificate of Cover. Where the schedule is issued at group level we will inform the individual employee of the specific details of the exclusion and the Certificate of Cover issued at group level will simply show that an unspecified additional exclusion applies to a given individual(s). Moratorium Underwriting For Moratorium underwriting, we do not need a medical declaration completed. Instead, we will not cover treatment of any pre-existing condition or any related conditions if you have had symptoms (even if a medical opinion has not been sought), medication, treatment, diagnostic tests or advice relating to that condition in a 60 month period prior to you joining the scheme. However, we may agree to cover a pre-existing condition, providing the condition does not remain present, including latently or in remission and only if you do not have symptoms, medication, diagnostic tests, treatment or advice relating to that condition during a continuous 24 month period after you join the scheme. Continued Moratorium Underwriting (Continued Mori) To consider continued moratorium underwriting we will require your previous insurance certificate, which will show us the commencement date of your original moratorium underwriting. Your previous insurance certificate must expire no earlier than the day prior to your commencement of cover date with us (if you have had insurance with more than one insurer since the commencement of your moratorium we will require proof of continuing cover). You will not be covered for any conditions, which existed, i.e., you have had symptoms of, even if a medical opinion has not been sought, in the last 60 months from your original insurance commencement date. Such conditions may automatically become eligible for cover, providing the condition does not remain present, including latently or in remission and only when you do not have symptoms, receive treatment, medication, tests or advice (from your G.P. or Specialist) for that condition for a continuous period of 24 months after your cover with us has started and immediately prior to any consideration of reinstating cover for that condition.
Continued Personal Medical Exclusions (CPME) Employer Paid We are prepared to consider accepting a group scheme presently insured by another provider on a no worse terms basis. This is often referred to as CPME (Continuation of Personal Medical Exclusions). The following conditions apply for us to consider accepting a scheme on these terms: The scheme must have been previously fully underwritten and any exclusions (or other appropriate endorsements) applied to any pre-existing conditions. Any scheme where more than 20% of the employees were accepted on Medical History Disregarded terms (MHD) will not be considered for CPME transfer. For companies and individuals numbering up to 9 who have completed the required documentation, undisclosed medical conditions on a CPME transfer will be rejected unless they are proved as being covered by the previous insurer. The scheme must satisfy the following criteria: a. A minimum of 2 employees. b. All covers are mandatory and fees are 100% employer paid. (Please note that part-time employees, employees over the age of 65 and those resident outside of the UK do not constitute the minimum employee requirement for the scheme to be considered). The following information is required for us to consider CPME transfer: a. For groups numbering up to 9, 3 years claims experience. If unavailable the reason must be stated in writing by client or broker b. Number and ages of employees. c. All Certificates of Insurance for each employee (and any dependents, where applicable) stating the underwriting terms and detailing any exclusions. If this information is not available, the original certificates from the previous provider will be required. d. A copy of the existing insurers offer of renewal. e. Disclosure of any members who in the last 36 months have been diagnosed with any heart, cancer or psychiatric condition. For previously uninsured people who join after the start date of cover with us, we offer the joining group/company the option of either: a) Full Medical Underwriting, or b) Moratorium Underwriting The choice has to be made at the scheme inception and can only be varied at renewal.
Continued Personal Medical Exclusions (CPME) Individual We are prepared to consider accepting an individual /family presently insured by another provider on a no worse terms basis. This is often referred to as CPME (Continuation of Personal Medical Exclusions).The following conditions apply for us to consider accepting an individual/family on these terms: You must have been previously fully underwritten and any exclusions (or other appropriate endorsements) applied to any pre-existing conditions. For individuals who have completed the required documentation, undisclosed medical conditions on a CPME transfer will be rejected unless they are proved as being covered by the previous insurer. You must satisfy the following criteria: Maximum age 75 and has had in place a fully underwritten Private Medical Insurance Policy for at least the last 12 months (Certificate of existing cover required) Does not have any treatment, investigations or tests planned, whether privately or via the NHS in the next 12 months. Has not undergone any treatment, investigations or tests within the last 24 months has not suffered from Cancer, Heart Disease, Stroke, Circulatory problems, Disease of the joints (including Arthritis / Rheumatoid Arthritis) or Psychiatric Illness (including stress related conditions) at any time in the past. For any additional, previously uninsured people joining the individual/family cover after the start date of cover with us, we offer the option of either: c) Full Medical Underwriting, or d) Moratorium Underwriting The choice has to be made at the scheme inception and can only be varied at renewal. Medical History Disregarded (MHD) For large group schemes we may offer underwriting terms on a Medical History Disregarded basis. Under the terms of this cover there is no requirement to complete any medical declaration and the moratorium clause does not apply. No exclusions will be based on the cover in respect of pre-existing conditions although the rules and benefits of the scheme purchased will still apply. Special terms apply allowing babies to be added to cover on Medical History Disregarded Schemes. We are prepared to consider accepting a group scheme presently insured by another provider on a MHD basis in accordance with the following criteria:
For Claims related, flat rated schemes with a minimum of 50 adult registrations, the following information is required for us to consider transfer: a. 3 years claims experience. b. Number and ages of employees. c. A copy of the existing insurers offer of renewal. For Community rated, age related, schemes with a minimum of 20 adult registrations, the following information is required for us to consider transfer: a. 3 years claims experience. If unavailable the reason must be stated in writing by client or broker. b. Number and ages of employees. c. A copy of the existing insurers offer of renewal. For MHD schemes generally 1. The scheme must have been previously insured or have been placed within a Trust Arrangement. 2. All fees are mandatory and 100% employer paid (part-time employees, employees over the age of 65 and those resident outside of the UK do not count towards the minimum employee requirement for the scheme to be considered). 3. Treatment for any employee in the last 3 years for conditions relating to the Heart, Psychiatric conditions or Cancer must be declared. 4. Additional members joining an existing MHD group or company currently insured with us but with less than 100 members will be subject to new moratorium underwriting terms. 5. For additional members joining an existing MHD group or company currently with us but with more than 100 members, us are prepared to accept the additional new joiners on Medical History Disregarded Basis with a 25% loading on our standard monthly fees. Adding a baby to cover on a Medical History Disregarded Scheme Where the group / company has opted for a premium loading to enable new joiners to be added on Medical History Disregarded terms, providing the mother has already been a member of the scheme for a minimum of 10 months, then an application to add the baby will be accepted on Medical History Disregarded terms, subject to the monetary limit applicable for the first 180 days of life. If the mother has not been a member of the scheme for 10 months, the baby will be added on a Fully Underwritten, or a Moratorium basis. We do not pay for any treatment to a child on cover for the first 30 days after birth.
If the group / company has opted to add new joiners on a Moratorium or a Fully Underwritten basis with no premium loading, providing the mother has already been a member of the scheme for a minimum of 10 months, if we receive the application for cover, within the first 30 days of the baby s life, he or she, can be added to cover without being underwritten. This means if the baby has a medical condition which has occurred between birth and being added to cover, providing the condition is eligible we will accept a claim for treatment of that condition subject to the monetary limit applicable for the first 180 days of life. We do not pay for any treatment to a child on cover for the first 30 days after birth. If the mother has not been a member of the scheme for 10 months, or the baby is over 30 days old, he or she will be added on a Fully Underwritten, or a Moratorium basis, subject to the monetary limit applicable for the first 180 days of life. We do not pay for any treatment to a child on cover for the first 30 days after birth. It is important to note, that although a baby may be added to cover very soon after birth and may be accepted on Medical History Disregarded terms, our healthcare schemes will only cover acute and curable events, which occur after the birthing process and are not congenital or believed to have been present since birth (whether inherited or caused by an environmental factor). Limits to cover: Where a baby has been added to cover on a Medical History Disregarded, basis there is a limit to cover for any eligible conditions that arise within the first 180 days of life of 5,000 in total. For any eligible conditions that arise after the first 180 days of life normal limits apply in accordance with the terms of the cover selected.
Continuation of Cover for Corporate Scheme leavers currently insured with General & Medical With a group scheme there will inevitably be individuals who leave the scheme and these individuals may wish to continue their healthcare cover with General & Medical. In these circumstances General & Medical will continue cover for the individual but at the fee rate, appropriate to that individual. Discounts, or preferential rates, applied to the group scheme will no longer apply to the cover available to leavers of the scheme. A scheme leaver wishing to continue cover with General & Medical will be offered an individual General & Medical policy, with no further underwriting. It must also be noted that individual policies may vary in benefits by comparison to the group scheme the individual has left. The scheme leaver becomes responsible for paying for their cover by monthly Direct Debit and all personal correspondence and relevant policy documentation will be issued direct to the leaver from the point of transfer to their individual policy onwards. Where a scheme leaver has been covered by a group scheme and had the further benefit of additional cover for their partner/spouse/family who were not themselves an employee of the company and therefore not a member of the scheme in their own right, General & Medical will not automatically accept these individuals onto an individual policy. We undertake to automatically continue cover only to the leaving member/employee; for whom cover may continue, as stated above, at the General & Medical fee rate, appropriate to that individual. At the time of transferring to an individual General & Medical policy from a Corporate Scheme, underwriting terms will be CPME. Where the scheme leaver has transferred from a Moratorium or MHD Scheme, this will be shown on the individual new policy documents as: Additional Exclusions: None. Transferred from Medical History Disregarded Scheme or Moratorium Scheme (as appropriate). Unless the individual on a moratorium scheme has additional exclusions added to their cover, in which case, these will be transferred to the new policy. Where the transfer is from CPME or Full Medical Underwriting any Additional Exclusions will be transferred to the new policy. General & Medical will consider offering cover to partner/spouse/ family of the individual leaving the group scheme, subject to completion of an application, on Full Medical Underwriting terms. In certain circumstances General & Medical may offer certain brokers the ability to offer CPME underwriting on an individual basis. If you have been given this facility, these are the terms and conditions for General & Medical to consider offering CPME on an individual basis.
We hope that the information provided in this booklet has provided answers to questions about underwriting. If there are any further questions please contact one of our Client Relations Co-ordinators who will be pleased to help.
0800 970 9442 General & Medical Insurance Ltd Registered in Guernsey No 43984 Normandie House, Rue a Chiens St Sampson s, Guernsey GY2 4AE General & Medical Insurance Ltd are authorised and regulated by The Guernsey Financial Services Commission Administered by General & Medical Healthcare General & Medical House, Napier Place, Peterborough PE2 6XN General & Medical Healthcare, a division of General & Medical Finance Ltd Registered in England No. 2421641 General & Medical Finance Ltd are authorised and regulated by the Financial Conduct Authority - FCA No 579509 which can be checked by visiting www.fca.org.uk General & Medical comply with the guidelines set by the Association of British Insurers for Health Insurance General & Medical Securities Ltd has a beneficial interest in General & Medical Insurance Ltd D-1008-V2.6