Medical Risk Criteria for Agents
The following rules no longer apply, as the federal health law makes it illegal for insurers to increase rates or decline coverage based on a person’s risk — with the exception of age and tobacco use. As a reference for pre-ACA laws, these underwriting criteria can help you understand how much the laws have changed.
The Risk Criteria section provides a summary of conditions commonly encountered in the medical underwriting process. The Risk Criteria and Risk Level for each condition includes the potential cost for treatment, therapy and medications. The greater the risk, the higher the Risk Level the applicant would be assigned.
Risk is increased by factors such as smoking, use of prescription medications and height/weight.
In some situations, the listed condition itself may present only a minimal health risk, but the treatment and/or use prescription medications increase the overall cost risk.
Prescription medications which exceed the acceptable cost range of an assigned risk level may result in a higher risk level being assigned or declination.
Body Mass Index
Body Mass Index, (BMI) is a measure of body fat based on height and weight. The BMI score is valid for both adult men and women, as well as children. Research data from the National Heart, Lung and Blood Institute has documented that BMI is a reliable indicator of total body fat which is related to the risk of disease and death. Aetna uses both BMI and Height/ Weight Ratio for the Applicant’s age to determine the level of risk.
• BMI 43 and greater is an automatic decline
• For Applicants with a BMI less than 43, the Build Chart is used to calculate the percentage increase for each Applicant.
How To Use The Build Chart:
1. Locate the appropriate chart for male, female or child.
2. Locate the applicant’s height in the left hand column.
3. Follow that row to the right until it intersects with the applicant’s weight range.
4. Note the Level Number (Examples L0, L4).
5. Reference the appropriate chart Age Band Chart for male, female or child, for the percentage increase to the premium.
Adult Male Build Chart
Adult Female Build Chart
Child Age 2 – 16 Build Chart
Percentage Rating Change for Build
BMI 43 and greater is an automatic decline. The table below is for BMI under 43. This percentage increase to premium is based on Height/Weight to age risk factors only.