Meeting with a Medical/HMO Insurance Agent
Bring your notes.
After discussing the issues of importance to you, you will be shown an application for the coverage.
Review the information in our Medical/HMO Insurance – The Application before your meeting.
Agents and Brokers
Interview agents or brokers by telephone before meeting with them. Find out exactly what their training and experience is. How long have they worked in the healthcare field? Are they captive (associated with one company) or independent (representing many companies)? With which companies? How familiar are they with the advantages and disadvantages of one plan or policy over another?
As with other lines of insurance, health care agents and brokers may be considered an extension of the company. If so, then the company may be responsible for honoring whatever representations the agent or broker made to you about the coverage at the time of sale. That responsibility may depend on a number of factors, including the laws of your state, whether you read the plan or policy when it was first given or sent to you, whether you have any evidence of the misrepresentation and other factors.
Once again, it is absolutely critical that you always take good notes of conversations with insurance representatives and that you store these notes in your insurance file. When it comes to meetings with agents, you should also keep all pamphlets, brochures or other promotional materials given or shown to you. Do not throw these notes or materials away. They could be worth thousands of dollars and more.
Changes in Coverage
Ask the agent:
Whether the health plan under discussion would be able to reduce your coverage, or benefits, after you have purchased it.
And whether the plan can reduce continuing benefits after you have contracted a particular injury or illness and
What notice must be given to you concerning reductions in coverage before those reductions can take effect.
These are very important considerations. Once an insured has contracted a serious medical problem his or her ability to find a new insurer may be limited. Therefore you have to know whether an insurer can reduce the coverage it is selling you in future years. It is important to address this issue whether the policy in question is individual, group or employment based.
Ask the agent who his contact is at the insurance company. Get that person’s name, phone number, email address and address. Ask if any of the materials shown to you, including any “proposal” came from the insurance company itself (as opposed to have been written up by the agent or the agency he or she is working for).
- What does the policy say about appealing adverse claims determinations within the company hierarchy? (before resorting to other options).
- Does the plan have a procedure permitting you to appeal an adverse claims decision? If so, to evaluate such a provision ask the following questions:
- To whom is the claims decision to be appealed?
- Is the appeals person or panel a truly independent/neutral party?
- What are the appeal procedures and are they fair?
- Is the appeal process prompt or can it drag on for weeks or more?
Binding arbitration provisions
Many medical coverage contracts now require the binding arbitration of any disputes arising under the policy. ADR provisions required under any insurance policy can be a real cause for concern. But with medical and HMO contracts this is especially so.
There is a big difference between a situation in which both sides choose a neutral mediator (who only has the power of persuasion to attempt to bring the sides together,) versus one in which a third party (who may or may not be neutral) is actually empowered to make enforceable, binding, decisions.
Most ADR provisions contained in medical and HMP contracts mandate that a hand-picked decision-maker be empowered to actually decide controversies. This decision-maker is substituted for the courts. This might seem to provide an efficient and expeditious means for resolving disputes; however, some ADR clauses are so one-sided that they are the basically allowing the insurer or HMO to serve as its own judge and jury. These types of ADR clauses should be avoided at all costs.
The ADR requirements under various policies can differ dramatically. If a policy you are considering has an ADR clause here are the questions you must to ask in evaluating it:
- Is the ADR clause optional or mandatory (unless waived or given up by the parties)?
- Who can demand ADR? The insurer, the insured or either?
- How long may either party wait before demanding ADR?
- Does the ADR process empower someone to make a final and binding decision or is the decision appealable?
- How is the ADR decision-maker to be selected? Is it a fair procedure aimed at choosing a truly neutral party?
- What ability do the parties have to obtain records or documents from the other side prior to the ADR hearing?
- Are formal rules of evidence used? What about briefing, expert testimony, attorney participation? In other words, how elaborate, time consuming and expensive, is the process that is set forth?
- Who pays for the cost of the ADR proceeding? The insurer? The claimant? Both?
Once again, remember to document your discussions carefully and store them in your insurance notebook or file.
Next: The Application