Insurance Fraud? How will this be caught?

[MrSockMonkey]

60 + male enrolled in Marketplace Silver Plan through an agent (not me). Fellow already knew what tobacco rate was. Goes to the agent who "didn't ask me about smoking and I didn't tell him". Agent exclaimed when fellow quoted what he knew to be $130+ per month......"Who told you that? Because you live in ....... county, the premium is 0."

So he goes with it. Now I know the app had to be signed one way or the other. This fellow is scheduled for surgery and says will not take smokes with him to the hospital.

My question is....what happens next? How do the insurers learn about misstatements on the application? And what happens when they do? Thank you for insight here. This is a hypothetical situation, for the record.

 

[Robert Barney]

He owns a policy that will not pay a benefit.

 

[BMC]

If a death claim is made, the carrier will ask for the death certificate. If he dies of any smoking related illnesses, they'll investigate further and realize he lied on the app. They probably will still pay the claim, but deduct the extra premiums they should have been receiving the entire time.

 

[Deadlily]

If a death claim is made, the carrier will ask for the death certificate. If he dies of any smoking related illnesses, they'll investigate further and realize he lied on the app. They probably will still pay the claim, but deduct the extra premiums they should have been receiving the entire time.

They can also rescind the policy and refund all premiums paid. Most courts would agree with that decision, due to the fraud.

 

[goillini52]

60 + male enrolled in Marketplace Silver Plan through an agent (not me). Fellow already knew what tobacco rate was. Goes to the agent who "didn't ask me about smoking and I didn't tell him". Agent exclaimed when fellow quoted what he knew to be $130+ per month......"Who told you that? Because you live in ....... county, the premium is 0."

So he goes with it. Now I know the app had to be signed one way or the other. This fellow is scheduled for surgery and says will not take smokes with him to the hospital.

My question is....what happens next? How do the insurers learn about misstatements on the application? And what happens when they do? Thank you for insight here. This is a hypothetical situation, for the record.

From one monkey to another....welcome to the Forum.

 

[adjusterjack]

How do the insurers learn about misstatements on the application?

They smell it.

And what happens when they do?

Then they turn over every rock until they find the source of the smell.

 

[scagnt83]

Guys, this is health insurance which is guaranteed issue no matter what. They will simply send him a bill for the difference in premium between his current rate and smoker rates.

 

[pfg1]

I was wondering how it went from health to life. Beginning to think I was a monkey too.

 

[goillini52]

I was wondering how it went from health to life. Beginning to think I was a monkey too.

Being a monkey's not so bad.

 

[sman]

Guys, this is health insurance which is guaranteed issue no matter what. They will simply send him a bill for the difference in premium between his current rate and smoker rates.

As I started reading through this thread I couldn't figure out why a couple of people were talking about "...will not pay a benefit" and "If a death claim is made". Especially when the first sentence of the OP had the words Marketplace Silver Plan.