Underwriting Risk Criteria

Risk Level of Conditions for a National Health Insurance Plan

The following is an excerpt from the pre-health reform underwriting guidelines of a national carrier, and what they consider risk factors for one of their comprehensive PPO plans. Understanding what a risk is considered by a commonly sold plan is equally as important as knowing the declinable conditions and medications. This consideration alters the ability for certain individuals to qualify for a plan or causes them to pay more as a result. Because these lists vary from one company to another, and by state as well, keep in mind this is one specific example and does not apply to all plans.

An applicant could have one of many conditions within their state’s look-back period, which would determine whether or not they could be approved for coverage. If an applicant had one of the conditions on the list of risk criteria, they would be rated up accordingly and issued an exclusion period at the discretion of the underwriter/agent. These charts indicate how much to rate up the individual applying on an approximate scale, based on the factors qualifying their condition as a risk.