Met with a new client today

Correct me if I'm wrong, but why would that example need to go on the application if the individual had not received treatment for 31 years? That is well past the usual 5-7 year requirements for most pre-existing conditions and would be case specific.

Because it's a current condition.

Ok, let's take another example and also real life. My niece's boyfriend has a brain tumor - small and benign and for now inoperable. He was diagnosed with it as a freshman in high school and the doctors left it at "well, there's really nothing we can do."

He's now a senior in college and 7 years have past with no treatments, no testing, no nothing.

Now - would you fail to disclose on the app that he has a brain tumor? If you're thinking that 7 years + no treatment = doesn't go on the app then pick up the phone and call anyone's prescreen department today.
 
Because it's a current condition.

Ok, let's take another example and also real life. My niece's boyfriend has a brain tumor - small and benign and for now inoperable. He was diagnosed with it as a freshman in high school and the doctors left it at "well, there's really nothing we can do."

He's now a senior in college and 7 years have past with no treatments, no testing, no nothing.

Now - would you fail to disclose on the app that he has a brain tumor? If you're thinking that 7 years + no treatment = doesn't go on the app then pick up the phone and call anyone's prescreen department today.

If she didn't disclose her "condition" to you and you asked all the questions on the app in the context that they require ie: "in the last 7 years have you been treated or will be treated for ___________(insert whatever condition you want) then how can you disclose what you don't know on an app?

If you feel jilted by this client you can always make a note to the underwriters about this "limp" that made you feel uneasy.
 
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Very true and that's called field underwriting. If a client never discloses anything to you past 7 years you're in the clear. It becomes an issue when a client tells you about something that happened more than 7 years ago yet it's a current condition. Then it goes on the app.

Heat attacks, in general, are flat declines regardless of when they happened - 5, 10, 15 years ago. If your client coughs up the info that he had a heart attack 12 years ago it's a decline and you pack your stuff and leave. If your client never mentions the heart attack and has received NO treatment at all over the past 7 years you're both fine. Gets tricky - huh?

Most apps have a section asking if the agent is aware of any condition not disclosed by the client. Aetna for examples asks this. Say you did the entire app and the client say "nope - don't smoke" - then you're pulling out of the driveway and you see him light up a cig through the window. Guess what - you need to note smoking.

The limp - in this example - mandates that the agent ask the client about the limp. It's actually quite simple "I noticed your limp, are you ok?" Then you can hear the story.

But witnessing the limp and doing nothing is violating field underwriting rules and your ethical responsibility to protect the insurance company. We are not "Robin Hoods" trying to help our clients beat the system. We have a dual role to protect both our client and the carrier.
 
Now - would you fail to disclose on the app that he has a brain tumor? If you're thinking that 7 years + no treatment = doesn't go on the app then pick up the phone and call anyone's prescreen department today.
I just got off the phone with Assurant's underwriting dept. and claims dept. about this specific issue. I'd imagine a tumor would be an automatic decline, so I opted to discuss endometriosis since I have some experience in helping clients with that condition. Here's what I was told.

If a client has endometriosis and has received any type of treatment or is currently monitoring the condition at home, it must be listed on the application as being pre-existing. That I already knew, but I threw in a what-if scenario.

If the same individual has the condition but HAS NOT sought any type of treatment, including physicals, nutrional therapy,testing, etc. for 5,10, etc. years it does not have to be listed on the application.

I'm not saying "I" wouldn't still list it on the application, nor would I be thrilled about taking on that type of client who neglects her health because my preference would be not to take the risk of having a potential claims issue. I'm just relaying what I was told.
 
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Bad example since it most cases it really doesn't matter what the condition is - it's standard or even preferred is no treatment has been sought.

In your example I'd absolutely put endometriosis on the app since by the very fact that no treatment has been sought it's standard and CYA for you and your client.

My point is you'll have to note any condition that would have an adverse affect on underwriting if that condition is present yet no treatment has been sought - hence my tumor and heart attack examples.

For the limp in question it's the agent's duty to ask the client about it since he witnessed it. If she was born with the limp it's likely standard and not even an issue. If she broke her leg now it's an issue.
 
For the limp in question it's the agent's duty to ask the client about it since he witnessed it. If she was born with the limp it's likely standard and not even an issue. If she broke her leg now it's an issue.

OK, but lets not run to the company yelling that the client is trying to commit fraud. Talk to the client before you talk to the carrier. Get the facts... don't jump to conclusions.

Al
 
But witnessing the limp and doing nothing is violating field underwriting rules and your ethical responsibility to protect the insurance company. We are not "Robin Hoods" trying to help our clients beat the system. We have a dual role to protect both our client and the carrier.

It's interesting how many agents miss this point. If you manage to get one 'by' underwriting, and get a client insured, and the client gets their claims paid (it happens), good for that client, bad for every other client you have with that carrier. This will cause a rate increase due to higher utilization because someone didn't get rated correctly.

In the P&C world, a lot of agents get paid underwriting / profitability bonuses. You can write bad drivers, but you have to rate them as a bad driver, and then everything works. P&C agents are great at knowing all sorts of little tricks to get better rates (which is why you should never buy your home / auto insurance online), but they have to be careful to not cause a problem for themselves by not protecting the rate, having a rate increase, losing a bunch of clients.

Same thing in health, but agents usually aren't held to profitability of their cases, at least not directly. In general, if you list the facts, the rates and the underwriters will work to protect the rate for the next client.

If I'm healthy, I don't want to pay extra premium simply because you slipped someone in without proper information.

Dan

P.S. This is why states are trying to mandate health insurance, so the healthy can help pay for the sick. It works well in government logic, not so well on most peoples pocketbooks.
 
If you asked all the questions on the app, you asked all the questions. You could note it in comments. But you really don' know and could you be laible for assuming something and causing a problem for the client? What if you're wrong?

If this person wanted to cheat, couldn't they just find another agent who would take the app over the phone? I mean, don't you folks have in your areas agents that will do anything to make a sale? I could understand a person's reluctance to meet face to face with an agent. We make people uncomfortable, or at least the perception is we make people uncomfortable.

I would note it on the app if it really bothered me and then simply park the commission and don't spend it if you're worried about a chargeback. It could be anything and everything. While chargebacks are a itch.. a consumer filed lawsuit against you for a false (you really don't know) accusation (possible) might cost you alot, including your license.
 
Most applications have a "catch all" question = "Have you "ever" had or been treated for any conditions not listed on this application?". If she has anything major go wrong, she will have a medical records reviewed and the policy will be rescinded. Especially if anything happens during the first two years.

She could be okay if it is just a sore knee or whatever and she has never reported it to a doc. I doubt that this is the case - she hasn't had insurance for 5 years and now wants it asap. She is planning on getting something worked on to fix that limp - good luck with this one, it will come back to bite you.

You should have the "talk" with her - let her know what happens when there is a claim submitted and a medical records review. This is one thing I always go over with the client prior to submitting any application. I know that many others here do as well. Usually, after educating them on the review process, they will "remember" a few thing not listed on the app.
 

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