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Chamber professionals offer expertise you can use today
Five questions to ask before
buying health insurance
Rebecca Bloomfield, Alliance for Affordable Services
Never buy a health insurance policy based on price alone. Instead, consider
these factors when making your buying decision.
What is the company rated The A.M. Best Company is the
oldest, most experienced rating agency in the world and has been reporting
on the financial condition of insurance companies since 1899.
The ratings the A.M. Best Company assigns are:
• A++ and A+ (Superior)
• A and A- (Excellent)
• B++ and B+ (Very Good)
• C++ and C+ (Marginal)
• C and C- (Weak)
• D (Poor)
• E (Under State Control)
• S (Suspended)
Buy from a company with a good rating. To see a current copy of the
company’s A.M. Best Report, ask your agent, ask for it at the public library,
go to www.ambest.com or call A.M. Best at 908-439-2200.
How are claims paid Health insurance companies use different
methods to pay claims. Two of the most common are Usual and Customary
charges and Reasonable charges. “Usual and Customary” charges are based
on provider charges in a given area: the smallest of the actual charge, the
provider’s usual charge or the prevailing charge for that service in a similar
location. “Reasonable” charges give the insurance company flexibility to
adjust the Usual and Customary charge if they determine a service charge is
unusual. Reasonable charges are typically less than the usual and customary
charges, and only the insurance company knows the actual value.
Beware of added extra words like “Usual, Customary and Reasonable”
charges (UCR), which may create loopholes for the company to decide how
much it will pay. Often it is not what the hospital or doctor charges, or
what the insured thinks it should be, resulting in misunderstandings.
If the company doesn’t use the Usual and Customary charges, look for
the following substitutes and be cautious of how it pays claims:
• reasonable charges
• average charges
• permissible charges
• negotiated fee
• allowable amount
• limited fee schedule
Can you go to any doctor, hospital or specialized health care
facility Some health insurance companies require pre-certification or a
referral before you can seek treatment. Choose a health insurance plan with
the greatest flexibility in choosing doctors and hospitals. Even if a doctor is
on the list, be sure that you have access to specialists and other doctors
whom you might want to see.
When faced with a serious illness or injury, most people want to know
that they can seek the very best medical care available.
Will your plan go where you want it to go Some health
insurance plants may not travel well. For example, some will not cover you
if you are outside of the United States. Even more restrictive, some plans
limit your benefits if you use them outside a particular jurisdiction, such as
a state or county. Many plans will not cover you if you relocate to another
state, requiring you to find new health coverage in your new state.
Choose a plan that provides worldwide coverage. The only thing worse
than having a medical problem while on vacation or a business trip is
finding out that it is not covered. Ask your agent what would happen if:
• you choose to go out of state for medical treatment, and
• how a medical problem would be handled if you were in a foreign
country.
Your health plan should cover you in the worst-case scenario.
What about on-the-job injuries Many health plans exclude onthe-job
injuries and many working Americans are not covered by worker’s
compensation plans. People who work several jobs or have businesses on
the side are usually not covered on-the-job by their primary employer’s
insurance. Plans that exclude work-related medical problems may:
• not pay for anything that happens at or because of work, and
• put off paying ANY claim while they “investigate” whether it was workrelated
or not.
If you are not covered by Worker’s Compensation or a similar plan or
law, be sure that you choose a plan that will cover you 24 hours a day,
whether you are working or not.
Many people find out how their health insurance policy works when they
submit a claim. Sometimes it is a rude awakening. Few people take the
time to understand the fine print until it’s too late. It is worth your time to
understand the facts . Choose a health insurance plan based on the quality
of the company and the plan. Then adjust the rates by adding or removing
benefits to make it affordable.
Make your buying decision based on your needs. Insurance is about
much more than low-cost prescriptions, doctor visits and the monthly
premium. Buy from a professional, licensed agent in whom you have
complete trust and confidence. Have your agent explain the plan. And
remember to get the phone number of your agent and insurance company’s
customer service division for information and assistance.
Rebecca Bloomfield is field service representation for The
Alliance for Affordable Services, a nation not-for-profit
organization. For more information about this article, call
Rebecca, 847-362-8888, or email rbloomfield@mw-ins.com.
Fall 2007 / 31