Gaming the System

Hardly a day goes by without someone suggesting ways to me to game the system in their favor. Since this is an insurance forum, you must have concluded by now the system is insurance. Specifically, health insurance. Even more specifically, individual health insurance (contrasted with group health insurance).

Last week I spoke to a lady who found a plan that was just like the one I suggested, but was 30% less in premium. Of course she did not know, nor did she care to hear that the plan also had 50% less coverage.

Before that I had a woman who complained that her $1000 per month health insurance premium was too high for the benefit she received. When I suggested a more reasonable $450 premium plus another $400 monthly into a HSA she balked saying she could not afford the $5000 deductible nor the out of pocket for her annual doctor visit. She insisted there MUST be a plan out there that is better than what she has but doesn’t charge as much in premiums.

Today, at 8:06AM I had an email from a lady who is pregnant (2 months) and wanted health insurance to cover her prenatal & delivery. This is the same woman I talked to last Thursday and explained that the only plan she could find to accomplish this feat was a small group plan through a major carrier. (She and her husband do own a small business that would qualify them under Georgia small group laws).

In today’s email she stated she had found another carrier who does not impose the same requirements for eligibility as the carrier I proposed, and the rates were lower for more coverage. She had reviewed the application for this carrier and determined this carrier does not require payroll records to substantiate qualifying for group coverage.

Due to her pre-ex condition, the rates on the proposal (mine as well as the other carrier) are not reflective of final rates which can change as much as 65% (for the other carrier) or 45% for my proposal. This may tend to level the playing field once final underwriting is concluded.

Neither carrier makes mention of supporting documents in the master application. Yet both carriers do require such documents.

I do not claim to have complete understanding of all aspects of health insurance and readily admit that I still learn things every week despite a long tenure in the industry. But one thing I do know is this. If you think you can beat the carriers at their own game you are wrong. They have been doing this a lot longer than any of us, and have probably seen it all. They also have high paid attorneys, actuaries and underwriters who know how to protect the carrier.

I know for certain there are no ways to beat the carriers at their own game. But I also know that when you understand the rules, and I feel I know them as well as any, you can work the system to your favor. If you think you have found a way to beat the carrier, most likely the only thing you have accomplished is finding a way for the carrier to deny coverage at some future date, once all the facts come to light.

Once you are in claim, that is not the time to find out your policy isn’t what you thought it was.