Assurant Individual/Supliment

[Krono]

Where did you see the part about not covering work related injuries? I don't know texas laws, but if workman's comp is not mandatory and the client gets an injury, the insurance company should pay the claim.

This is under their exclusions clause:

"charges for work-related sickness or injury eligible for benefits under worker’s compensation, employers’ liability or similar laws even when the covered person does not file a claim for benefits"

Sorry...I read it wrong. According to this statement, it looks like they will cover it if worker's comp (not required in TX) doesn't pay.

 

[Crabcake Johnny]

Yes. They will pay a work-related claim only if the client is not covered by workers comp or isn't required to have it. Glad you post stuff like that here actually - this board is a good source for training.

 

[Krono]

My bad...see above response.

 

[J.R.]

This is under their exclusions clause:

"charges for work-related sickness or injury eligible for benefits under worker’s compensation, employers’ liability or similar laws even when the covered person does not file a claim for benefits"

Sorry...I read it wrong. According to this statement, it looks like they will cover it if worker's comp (not required in TX) doesn't pay.

Don't worry about it, I was in the same boat 2 weeks ago when a client asked me a similar question. Called the MD DOI and they have no #$$#$@ idea about what was required nor who to talk to about what is required, except to say that there are state mandates. Really, good to see the college education is paying off for you Next step was Assurant and I got the information I need. Final step was a short discussion with John P. to get his input.

 

[Crabcake Johnny]

I can guarantee you that right after my Mega experience I was calling the claims departments of the carriers I hooked up with to get clarification on how the plans actually worked. Most claims reps are more than happy to talk about it - especially when you convey that you want to sell the plans properly. Brochures? Throw them in the trash regarding training. They do not convey the state mandates nor properly explain how the plans actually work.

 

[Krono]

Yep...insurance can be confusing.

But with this in mind...I thought of something else. Coremed policy specifically sez they don't cover "work-related sickness or injury eligible for benefits under worker’s compensation". I don't know anything about workman's comp...but isn't that in effect saying that the person is limited by the worman's comp plan?

For example...say a person has a workplace injury and the doc bills pile up to $250,000...but the wordman's comp plan the employer has is a cheezy low budget policy and only covers $25,000 per injury (not sure if wordman's comp works that way...mind you). According to their exclusion clause, the person is screwed because they were merely eligible for benefits...at whatever amount.

Bottom line is I think the exclusion clause is WAY too ambiguous...

 

[Crabcake Johnny]

I'm not exactly sure that this has to do with CoreMed. Not a single carrier in MD is gonna touch a work-related claim if they're covered by Workers Comp. And who says workers comp doesn't jerk people around? In many cases you end up in court.

Krono - are you saying you know of a carrier that will pay medical claims if someone's covered by worker comp?

 

[Krono]

John...I guess what I am saying is I don't know enough about it...I am trying to learn...understand this stuff.

Two different plans from Assurant have different exclusions. I understand that part. But what confuses me is that the CoreMed exclusions specifically discuss workman's comp while their MaxPlan totally ignores it. Here are their exclusions direcly from Assurant's website:

CoreMed: "Exclusions consist of the following but are not limited to: charges for treatment of behavioral health or substance abuse, charges that are related to or a complication of a pre-existing condition, charges that are not specifically listed as a covered charge in the medical benefits section or outpatient prescription drug benefits section, charges for work-related sickness or injury eligible for benefits under worker’s compensation, employers’ liability or similar laws even when the covered person does not file a claim for benefits, charges for which a covered person is entitled to payment under any motor vehicle medical payment or premises medical expense coverage, charges caused by or contributed to by war or any act of war, whether declared or undeclared, charges for vision care that is routine, except as otherwise covered in the diabetic services provision in the medical benefits section, charges for hearing care that is routine".

MaxPlan: "Exclusions consist of the following but are not limited to: war or any act of war, whether declared or undeclared, vision care that is routine, except as otherwise covered in the Diabetic Services provision in the Medical Benefits section, care that is routine; any artificial hearing device, cochlear implant, any diagnosis, supplies, treatment or regimen, whether medical or surgical, for purposes of controlling the covered person’s weight or related to obesity or morbid obesity, whether or not weight reduction is medically necessary or appropriate, charges for growth hormone therapy, charges related to maternity or pregnancy, or routine well newborn care including nursery charges at birth, or non-spontaneous abortion, genetic testing or counseling, infertility diagnosis and treatment for males or females".

As you can see...the MaxPlan exclusions totally ignore workman's comp.

If plans won't pay when workman's comp kicks in...would it say it? And if so...why would they only mention it on the CoreMed plan?

 

[Crabcake Johnny]

Max plan's not covering anything work related when worker's comp is in force. Neither is CoreMed or anything else. IF and only IF a work-related claim is filed and the client isn't required to carry worker's comp all carriers I know of pays the claim.

 

[somarco]

Here's a thought.

Go to https://www.assuranthealthsales.com/414/sales/Login.aspx and download a specimen contract. Download a Core Med specimen contract for your state. Then read it.

My guess is you will find something like this in the contract.

Charges for work-related sickness or injury eligible for benefits under workers comp . . . even when the covered person does not file a claim (are not covered).

3) A covered person who is not required to have coverage under workers comp . . .

Brochures are mostly worthless. You need to read and understand the contract. Claims adjudicators pay claims based on the contract, not what a salesman says.