Walter van der Wal

Getting claims paid

Three types of health insurance buyer


As a rule, there really are no good or bad companies when it comes to paying claims, although some are a little better than others. It's mainly a matter of timing and situation. Most insurance companies pay their claims promptly, just the way we expect them to. But...sometimes they don't.

Why? To understand that, you first need to understand that while insurance companies are in the business to provide a needed service, they are also in the business to make a reasonable profit and not to lose money.

Premiums are figured by mathematicians (actuaries) who try to predict the cost of paying out claims for a given population. Projected operating costs for doing business are also added in. If their claim predictions are too high, the company makes a profit. If they are too low, the company can end up paying out more in claims than it is earning in premiums.

Basically, there are 3 types of medical insurance buyers:

1. Sincere. Most buyers fall into this category. They aren't aware of any health problem. They just want to be protected in case they do develop one in the future. Others, who do have a health problem, accept the fact that the problem won't be covered in their policy.

2. Naive. These buyers wait until they actually have a need for medical treatment before they try to buy medical insurance, innocently believing that the insurance company will pay for their treatment. They are shocked when they learn that it won't. Some get quite angry at the insurance company. (One called me from the hospital the day after he had submitted his application and wanted to know where his hospital card was. He had scheduled himself for an operation even before he had submitted his insurance application).

3. Fraudulent. These buyers knowingly lie on their application in order to be covered for treatment of medical problems they know they already have. What they don't realize, though, is that the insurance company will usually discover their lie when the insured seeks treatment for that medical problem, or even seeks treatment for an unrelated, legitimate medical problem. (Just this year, 2 of our insureds' policies were cancelled when they sought treatment for serious medical problems that they had tried to hide; and, another insured had a number of new exclusions added to his nearly 2 year old policy).

In order to help guard against high losses, insurance companies hire people called underwriters to screen applications looking for pre-existing medical conditions that could eventually cost the company a lot of money in medical claims. They rely on the honesty of the applicants to do their job. The fraudulent applicants normally slip through this screening.

The insurance companies, though, still have 2 years from the time of application to find and exclude any pre-existing conditions that the applicant was unaware of or had lied about. After that, only serious cases of fraud provide grounds for rejecting claims for treatment of medical conditions not already excluded in the policy..

The people hired to evaluate and approve medical claims are called claims adjusters. One of their responsibilities is to help save the insurance company money by spotting "red flags" that warn of possible fraudulent claims. Their job is to make certain that the insurance company does not pay out any more than it is required to in accordance with the insurance contract. On a more positive note, though, their job is also to process the claims as speedily and efficiently as possible

Claims adjusters can tend to be very cynical people, constantly on the lookout for red flag warnings. If they allow invalid claims to be paid, though, they will needlessly cost the insurance company money. This cost (along with rising medical care costs) will be passed on by the insurance company to its population of insureds in the form of higher premiums

Fortunately, most insurance claims are speedily processed without any problem. Insurance companies tend to pride themselves on this. But, if a red flag pops up during the claim process, watch out! Expect delay.




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