1. finance
2. personal finance
3. insurance

DISCLAIMER
This Field Guide was developed as a tool to aid the
agent/broker community in understanding the
Underwriting and Administration practices at American
Community Mutual Insurance Company. The Guide is
located on the web site; the version on the web site will
always be the most current version available. It is our
intent to update the Guide as soon as changes are
made. However, please be advised that the
Underwriting and Administration areas at American
Community reserve the right to change processes and
guidelines without prior notification. While we will make
every attempt to avoid making changes without
notice, Agents are encouraged to use the web-based
Field Guide as their single-source reference.
Table of Contents
Introduction ............................................................................. 5
Underwriting Philosophy....................................................................................... 5
Misrepresentation ................................................................................................. 5
Sensitive Cases ...................................................................................................... 6
Managing Difficult Situations .............................................................................. 7
Preparation ............................................................................................................ 7
Cover Letters ......................................................................................................... 8
Underwriting Assistants Support .......................................................................... 8
The Underwriting Process Flows ........................................................................ 10
Selecting the Correct Application ............................................................ 10
Review Special Consideration ................................................................... 11
Determining the Effective Date ................................................................. 12
Corrections and Signatures ........................................................................ 13
Submitting the Application and Collecting Payment............................ 14
1 Selecting the Correct Application................................1-1
An Introduction to Applications and Forms...................................................1-1
Types of Applications and Forms.....................................................................1-1
Short-term Applications ....................................................................................1-3
Prescreen Forms .................................................................................................1-3
Permanent Applications...................................................................................1-4
Replacing Another Carrier’s Insurance ...................................................1-4
Rewriting Current ACMIC Policy/Certificate ..........................................1-5
Reinstatement Applications.............................................................................1-6
State Uninsurable Health Insurance Plans......................................................1-6
2 Writing Short-term Applications .....................................2-1
Online Application.............................................................................................2-1
Eligibility ...............................................................................................................2-2
Signing the Application ....................................................................................2-2
Required Signatures....................................................................................2-3
Coordinating a Short-term Plan to a Permanent Plan.................................2-3
Premiums Payable .............................................................................................2-4
Selecting a Billing Option ...........................................................................2-5
Selecting a Payment Option.....................................................................2-5
Paying by Check or Money Order ...........................................................2-5
Paying by Electronic Funds Transfer (EFT)................................................2-5
Paying by Credit Card ...............................................................................2-6
Determining Effective Dates ............................................................................2-6
2
Introduction
3 Completing Prescreen Forms ........................................3-1
Eligibility ............................................................................................................... 3-1
Completing a Prescreen Form ........................................................................ 3-1
4 Writing Permanent Applications....................................4-1
Eligibility and Schedule of Persons Proposed for Insurance ....................... 4-1
General Guidelines ........................................................................................... 4-2
Existing Coverage and Replacement ........................................................... 4-4
Health Insurance Portability and Accountability Act (HIPAA) ................... 4-4
Premiums Payable............................................................................................. 4-6
Selecting a Billing Option........................................................................... 4-7
Selecting a Payment Option (non-List Bill).............................................. 4-7
Paying by Check or Money Order........................................................... 4-7
Paying by Credit Card ............................................................................... 4-7
Paying by Electronic Funds Transfer (EFT) ............................................... 4-8
Paying by List Bill.......................................................................................... 4-8
Plan of Health Insurance ................................................................................ 4-10
Contraceptive Coverage Opt-Out ....................................................... 4-10
Non-Medical Underwriting Questions .......................................................... 4-10
Part II - Medical History ................................................................................... 4-10
Determining Effective Dates.......................................................................... 4-11
Declarations and Consents ........................................................................... 4-13
Change in Health Status ................................................................................ 4-13
Trust Participants .............................................................................................. 4-14
Part III - Authorization to Obtain PHI ............................................................. 4-14
Required Notices to Applicant............................................................... 4-14
Signing the Application .................................................................................. 4-15
Application Preparation and Proper Completion ..................................... 4-16
5 Writing Reinstatement Applications..............................5-1
Eligibility ............................................................................................................... 5-1
General Guidelines ........................................................................................... 5-3
Schedule of Persons Proposed for Insurance................................................ 5-4
Medical and Non-medical Underwriting Questions .................................... 5-4
Determining Effective Dates............................................................................ 5-5
Signing the Application .................................................................................... 5-5
Required Signatures ................................................................................... 5-6
Authorization to Obtain PHI ............................................................................. 5-6
Introduction
3
6 Dependents and Existing Policies/Certificates ............6-1
Adding Dependents to an Existing Policy/Certificate .................................6-1
Coverage for Newborns ............................................................................6-1
Coverage of Adopted Children...............................................................6-2
Removing Dependents From an Existing Policy/certificate........................6-2
7 Risk Selection ...................................................................7-1
Medical Records................................................................................................7-1
Paramedical Examinations ..............................................................................7-2
Procedures Regarding HIV Consent Forms .............................................7-2
Blood and Urine Analysis ............................................................................7-2
Alkaline Phosphatase .................................................................................7-3
Bilirubin ..........................................................................................................7-3
BUN (Blood Urea Nitrogen) ........................................................................7-3
Cholesterol ...................................................................................................7-3
Creatinine.....................................................................................................7-3
GGT (Gamma-Glutamyl Transpedtidase)...............................................7-3
Glucose.........................................................................................................7-3
LDH (Lactic Dehydrogenase)....................................................................7-4
SGOT (AST) and SGPT (ALT)........................................................................7-4
Triglycerides..................................................................................................7-4
HIV Blood Test ..............................................................................................7-4
Nicotine Testing of Urine Specimens ........................................................7-4
Additional Data Sources...................................................................................7-5
Medical Questionnaires....................................................................................7-5
Medical Risk Selection Criteria.........................................................................7-5
General Information ...................................................................................7-5
To Change Tobacco Use to Non-Tobacco Use Status .........................7-6
Short-term Field Underwriting ....................................................................7-6
Substandard Risk .........................................................................................7-6
Health Insurance Build Charts (Adult and Juvenile)..............................7-6
Health Insurance Build Chart.....................................................................7-8
Juvenile Build Chart ....................................................................................7-9
Unacceptable Medical and Non-medical Conditions ......................7-10
Medical Risk Guide ...................................................................................7-12
Non-Medical Risk Selection Criteria ..............................................................7-31
Occupations ..............................................................................................7-31
Avocations .................................................................................................7-31
Aviation Activities......................................................................................7-32
Foreign Travel.............................................................................................7-32
Non-US Citizens ..........................................................................................7-32
4
Introduction
8 After the Applicant Has Signed.....................................8-1
Sending the Application to ACMIC ............................................................... 8-1
Faxing the Application............................................................................... 8-1
Status ............................................................................................................ 8-1
Policy Delivery Procedures............................................................................... 8-1
Policy Delivery Requirements.................................................................... 8-2
Delivery Requirements and Not Taken Out (NTO) Policy Procedures 8-3
Changes to a Pending Policy................................................................... 8-3
Changes to an Active Policy .................................................................... 8-3
Withdrawn Applications ............................................................................ 8-4
Closing Underwriting Pending Files .......................................................... 8-4
Rated or Declined Applications............................................................... 8-4
9 Appeals ............................................................................9-1
Rated or Declined Applications ..................................................................... 9-1
Adverse Underwriting Determinations in Arizona, Illinois, and Ohio .......... 9-1
Appeals and Disclosing Information .............................................................. 9-2
Appeals ........................................................................................................ 9-2
Removal of Riders/ Smoking Ratings ....................................................... 9-2
A Contact Information...................................................... A-1
B Forms, Questionnaires, and Surveys..............................B-1
Health Application Checklist........................................................................... B-1
List of Applications, Forms, and Questionnaires ........................................... B-2
Applications, Forms, and Questionnaires Sorted by Name ................. B-2
Applications, Forms, and Questionnaires Sorted by State ................... B-5
Glossary................................................................................G-1
Index....................................................................................... I-1
Introduction
5
Introduction
Underwriting Philosophy
To establish appropriate health insurance underwriting expectations, American Community
Mutual Insurance Company (ACMIC) uses the following philosophy:
The ultimate goal of underwriting is to fairly and accurately place each insured into a broad
risk category with appropriate morbidity and mortality/claims expectations. The Medical
Underwriting Department recognizes that providing high quality service to agents and
applicants is essential. The various departments’ processing of new business for applications
in the Home Office will regularly critique their own practices and procedures looking for
ways to improve service. We will review suggestions from our Field Force and from
insureds. We will implement new policies and procedures to maintain high quality service
that is acceptable to our Field Force.
ACMIC’s underwriting is performed in a manner consistent with prescribed lay and medical
underwriting standards that are outlined in our rating manual. These standards serve as
guidelines to aid the underwriter in making a final decision. Our underwriting standards are
based on the best available data from many sources, including the Company’s morbidity
results, the medical judgment and knowledge of our medical director, underwriting
management, health care utilization data repositories, plus insurance and clinical literature.
We will continue to regularly review the medical and lay material and update standards as
appropriate.
The Medical Underwriting Department must remain competitive in its underwriting
decisions. This is essential to maintain our Field Force and is a prime factor in providing
quality service. We will continually monitor the actions of our major competitors to ensure
that we maintain our competitive position.
Misrepresentation
Misrepresentation of significant information negatively impacts the quality of the
underwriting process and is costly to insurers of health products. For health,
misrepresentation takes on heightened significance because of the working relationship
6
Introduction
necessary between the insured and Claims Department when the request for benefits is made.
Much of the detail required to service a claim is subjective and prone to manipulation. After
a health policy is issued, the potential exists for a long-term claim relationship; through one
long-term claim, several recurrent claims, or different claims over the life of the contact.
ACMIC will avoid entering into a contract when the misrepresentation of the application is
uncovered and calls into question the insured’s credibility and truthfulness. Trustworthiness
is essential to this potential long-term claim relationship. From a mutuality and fairness
standpoint, insureds who have been frank and open should not be put in the position of
subsidizing the poor morbidity experience of those who misrepresent.
The act of misrepresentation is subject to underwriting. Underwriting will be discontinued,
and the applicant will be declined when the misrepresentation of a material fact brings into
question the credibility of the application and other crucial information used in
underwriting. Material misrepresentation raises the issue of whether the insured is applying
for the policy with the intent of filing a claim, whether the information the insured would
provide to substantiate the claim is credible.
If a misrepresentation is discovered at claim time, the underwriter will be asked: “If you had
known this information or the correct information at underwriting time, what would you have
done?”
1. Issued the policy as you did.
2. Offered to issue the policy only if the applicant accepted an exclusion rider or extra
premium.
3. Declined the application.
If the answer is 1 and the policy remains in force, the claim is payable unless another
provision of the policy makes it not payable – for example, it may be a “pre-existing
condition” and excluded for a certain period.
If the answer is 2, the insured is offered a chance to reform the contract (i.e., accept the rider,
rate up or have the policy rescinded).
If the answer is 3, the policy is rescinded.
Sensitive Cases
Often an agent will recognize a potentially sensitive case early in the sales process. When
such a case is identified, there are several steps that can be taken that will make both the sales
process and the underwriting process easier. The more you can do to help the Home Office
Introduction
7
underwrite the case, the more you improve your chances of getting your client a better
policy.
Managing Difficult Situations
Ask for help. It is better to ask before acting, if there is any doubt. When asking for help,
have all the necessary facts ready. Not having the needed information will delay getting the
necessary answers.
Questions to ask:
Agents should contact their Regional Marketing Director for planning ideas.
Call the National Sales Office for illustration and software questions.
Call the Medical Underwriting Department for specific impairment questions. Our
underwriting assistants can also help with preliminary underwriting questions.
Call the Call Center for service related information.
Good records can be very helpful. Agents should keep track of whom they speak with,
when they had the conversation, and what was said.
Preparation
Prepare clients for the underwriting process: the length of time involved, the need for
additional requirements, and the expected outcome.
ACMIC underwriters try to process applications quickly and efficiently. However, due to
delays in receiving Attending Physician Statements (APS’s or medical records), results from
testing labs, etc., the underwriting process might take several weeks to complete. These
delays do not mean ACMIC has a problem or concern with issuing the policy. ACMIC
underwrites applications in a careful and efficient manner in order to provide the best
possible protection for all its policy owners.
Occasionally, an underwriter might require additional medical information, details, or tests
before a decision is made. By asking for more information, the underwriter is ensuring the
client the best decision possible. In most cases, having additional information allows the
underwriter to issue the policy with a better classification than if the information was not
available.
8
Introduction
Cover Letters
The agent often knows the client very well and can help the Home Office underwriter fill in
the picture of who the client is through the use of a good cover letter. In those cases
involving unusual circumstances, a cover letter is a must. What to include can sometimes
create a dilemma. You are helping us if you can elaborate on the following:
Summarize the application. Include the client’s name, the plan of insurance, the
beneficiary, and the owner (for health savings accounts if indicated).
Any underwriting problems known to you.
Provide us with the complete names, addresses, and telephone numbers (including area
code) of all attending physicians.
Detail the need for the insurance. Why is the policy being purchased?
The competitive nature of the case (what other insurers have previously reviewed the
case and their decisions).
Which applications are currently pending or being contemplated with other companies?
Are any replacements planned? Include who the competition is and where they are in the
underwriting process.
Has there been any action by other companies on the client in the last five years? We
especially need to know about any policies that were issued other than standard.
Do you know the client personally? How close is your relationship? How frequently do
you see the client?
What special time limits does the Medical Underwriting Department need to be aware of
to meet the client’s expectations?
The more thorough the letter, the easier you make the underwriting process and the faster
the policy will be issued. The Field-Home Office partnership is strongest when we work
together on difficult cases to ensure success.
Underwriting Assistants Support
ACMIC’s underwriting assistants are well versed in all aspects of the application process.
They are your liaison while your application is in the Medical Underwriting Department.
They are responsible for screening the application for completeness, accuracy and then
entering the application on the Individual Administration System. Should you have any
questions regarding your application while it is in the underwriting process, general status
calls can be directed to the Customer Service Line or the National Sales Office. More
specific information and assistance can be obtained from the underwriting assistants.
Introduction
9
10
Introduction
The Underwriting Process Flows
Selecting the Correct Application
Start
Is the agent
licensed in
the state?
N
Review the
Agent
Appointment
Guide for
instructions
Y
Complete the
33-27-H and
mail to ACMIC
Y
Submit to Policy
Issue and pay
by EFT or credit
card
Y
Not eligible
Y
Applicant
resides in
state of
application?
Y
Is this a
prescreen
application?
Y
N
Complete the
Prescreen
Application and
fax to ACMIC
Is this a reinstatment?
N
Is this a
short-term
application?
N
Applicant
< 2 weeks
old?
Is applicant
a good
candidate?
N
A
Y
Is the
applicant
> 64 years
old?
N
Y
Select HSA-1 or
HA-1 application
specific for the
state
Complete a
Medicare
Supplement
Application
B
N
A
Introduction
Review Special Consideration
B
Dependents?
Y
Is this a
child-only
policy?
Y
Review childage signature
requirements
and premium
ratings
N
N
List dependants,
grandchildren
too if
dependants.
Review the Risk
Selection
Criteria
Review Special
Considerations
C
Signature Age Eligibility Requirements:
The child must be 15 days to 18 years old
A parent or guardian must sign for children under 16 years of age. Note: In Missouri, a
parent or guardian must sign for children under 18 years of age.
Full-time student eligibility requirements
Refer to Chapter 7 - Risk Selection Criteria
11
12
Introduction
Determining the Effective Date
C
Y
Replacing
long-term
coverage?
N
Y
Replace
existing
ACMIC?
Y
N
Effective date =
paid-to-date of
current policy
Qualified
under
HIPAA?
Y
N
Ending
COBRA?
Y
N
Effective date
assigned by
ACMIC > 30
days
Effective date
assigned per
request or paidto-date of the
current policy
D
Introduction
Corrections and Signatures
D
Agent obtain
completed
application from
the client
Review the
application, then
sign and date
the application
E
Are
corrections
required?
Y
Error in date
or signature?
N
N
Client to take
"Notice of
Privacy Rights"
page
Line out error,
print correction,
applicant initials
F
Y
Shred
application,
begin again
A
13
14
Introduction
Submitting the Application and Collecting Payment
F
Select payment
method
Select payment
period
Paying by
EFT or credit
card?
Y
N
Paying by check
Faxing
application?
N
Mail application
with payment
Y
Fax application
Application
accepted?
N
Physically return
application with
payment
Y
File original
application
Follow up with
the quote
A
End
E
1 Selecting the Correct
Application
An Introduction to Applications and
Forms
The application is part of the policy/certificate to which it is attached, and is therefore part of
the legal contract between American Community Mutual Insurance Company (ACMIC) and
the client. The application is subject to all the terms and conditions of the policy/certificate
not inconsistent with it.
To ensure compliance with state regulations, all applications are filed and approved by the
state in which the policy/certificate is solicited and sold. ACMIC will not accept any
application that has not been filed and approved, is obsolete, or is for a state other than the
state in which the policy/certificate is being purchased. Applications must be completed,
signed, and dated in the state where the business is solicited, where the applicant resides, and
must also be a state in which the agent is licensed.
Incorrect versions of applications cannot be processed and must be returned to the agent.
Correct versions of the application can be obtained on the ACMIC Web site
(www.american-community.com) or through a request made to the National Sales Office.
NOTE:
Applications cannot be solicited, taken or dated prior to the agent’s appointment
to represent ACMIC. Commission cannot be paid on business solicited prior to an
appointment.
Agents must be licensed in the state(s) where they solicit business prior to becoming
appointed by ACMIC. Only agents licensed in the state will be allowed to solicit and submit
business for ACMIC.
Types of Applications and Forms
There are four types of applications and forms: short-term, prescreen, permanent, and
reinstatement.
American Community Mutual Insurance Company
Rev. April 2005
1-2
Selecting the Correct Application
Start
Is the agent
licensed in
the state?
N
Review the
Agent
Appointment
Guide for
instructions
Y
Complete the
33-27-H and
mail to ACMIC
Y
Submit to Policy
Issue and pay
by EFT or credit
card
Y
Not eligible
Y
Applicant
resides in
state of
application?
Y
Is this a
prescreen
application?
Y
N
Complete the
Prescreen
Application and
fax to ACMIC
Is this a reinstatment?
N
Is this a
short-term
application?
N
Applicant
< 2 weeks
old?
Is applicant
a good
candidate?
N
A
Y
Is the
applicant
> 64 years
old?
N
Y
Select HSA-1 or
HA-1 application
specific for the
state
Complete a
Medicare
Supplement
Application
B
Rev. April 2005
N
A
American Community Mutual Insurance Company
Selecting the Correct Application
1-3
Short-term Applications
Short-term applications are an interim health insurance plan for individuals transitioning
from one permanent health plan to another. Short-term insurance is not intended to be of a
permanent nature and is not renewable.
Short-term plans can be issued to people who:
Are less than 64 years of age and are not covered under any other medical expense plan.
Are not, nor is any dependant, pregnant.
Have not been declined for insurance due to health reasons.
Have not lived outside the United States, Australia, Canada, England, Ireland, Scotland,
or New Zealand within the past 12 months.
Have no health insurance coverage.
Able to answer “no” to all parts of the questions concerning medical conditions and
alcohol or drug use.
Any applicant who answers “yes” to any question is ineligible for the issuance of a
policy/certificate. Other applicants will be eligible based on their individual responses.
Short-term applications are available in printed versions and electronically online. (Contact
your Marketing Support Specialist or the National Sales Office to view the link and request
the URL with the instructions on establishing the link.)
Prescreen Forms
Agents can use prescreen forms to quickly receive an underwriting assessment of risk based
on minimal medical information. These underwriting opinions are helpful to determine the
action that Medical Underwriting might take when faced with a particular set of
circumstances. For example: the interaction of multiple medical conditions that might be a
decline; or risk assessment for recurrent conditions, whether a condition can be rated or have
a rider added.
The prescreen form is one page long. A prescreen form can be completed entirely by an
agent and does not require the applicant’s signature.
American Community Mutual Insurance Company
Rev. April 2005
1-4
Selecting the Correct Application
Permanent Applications
Permanent applications are used to apply for a policy/certificate that will be kept in place for
at least one year. Short-term applications are used to apply for coverage of less than one year.
The permanent application is used for clients who:
Are seeking health insurance without current permanent coverage.
Have allowed their ACMIC policy/certificate to lapse more than one year.
Want to replace another health insurance carrier.
Want to modify their existing ACMIC coverage.
Want to add dependents to an existing policy/certificate.
Want to apply for a HIPAA coverage in states where ACMIC issues HIPAA
policies/certificates (Arizona, Missouri, Ohio).
All permanent applications are subject to underwriting.
Replacing Another Carrier’s Insurance
Replacing health insurance is defined as any transaction in which a new accident and health
insurance is to be purchased; and it is known to the agent, broker, or insurer at the time of the
application that, as part of the transaction, existing accident and health insurance has been or
is to be lapsed or the benefits substantially reduced.
Some states have specific requirements regarding the replacement of health insurance.
Applications received from these states must be submitted with the required replacement
notices. These notices, approved by the state, clearly explain to the applicant factors that
affect their protection under the new policy/certificate. These factors can include pre-existing
conditions, accuracy of completing an application and rescission. Applications submitted
without the necessary notices will be returned to the agent. Any applicant who plans to
replace coverage should be informed by the agent not to cancel existing insurance until the
new ACMIC policy/certificate is approved and delivered.
Replacement notices need to be completed at the point of sale if the applicant is replacing
individual coverage other than American Community Mutual Insurance. Copies should be
included with the application and forwarded to the Home Office - otherwise the application
cannot be accepted (notices cannot be secured on delivery of the policy/certificate).
NOTE:
Illinois applicants must complete health replacement form RAS-IL.
NOTE:
Iowa applicants must complete health replacement form RAS-IA.
Benefits will be paid for a sickness, injury, or condition that first appeared (made itself
known) prior to the effective date of the ACMIC policy/certificate only if such sickness,
Rev. April 2005
American Community Mutual Insurance Company
Selecting the Correct Application
1-5
injury, or condition is fully and completely disclosed on the new application and not
excluded from coverage by a rider or policy/certificate exclusion. New coverage is not
effective until ACMIC approves the application and all delivery requirements are met.
Agents can order supplies by calling the National Sales Office. Agents who have questions
regarding permanent policies/certificates may contact their customer service representative or
the National Sales Office.
Rewriting Current ACMIC Policy/Certificate
Rewriting health insurance is defined as any transaction in which a current ACMIC
policy/certificate holder wants to apply for a new plan of insurance or change benefits, and
can qualify within the risk selection requirements. These requirements include:
The original policy/certificate is now in force.
No claims, other than wellness benefits, have been submitted on the existing
policy/certificate.
No applicant has been rejected, rated or restricted for any health, life or critical illness
insurance since the approval of the in force policy/certificate.
No applicant has had any symptoms, illness, or sought treatment for any type of medical
problem, including the use of alcohol or drugs since the original policy/certificate was
approved. Because a new (or existing) PE period will begin, illnesses covered under the
original policy/certificate might be pre-existing under the new policy/certificate.
Existing policy/certificate holders may apply for a different Individual Health
policy/certificate with ACMIC at any time. However, if they are accepted, the new
policy/certificate issued will have a:
New effective date
New deductible
New contestability period
All rewrites of a current policy are fully underwritten. Any applicant who plans to rewrite
their coverage should be informed by the agent not to cancel existing insurance or stop
paying premiums until the new ACMIC policy/certificate is approved and delivered. They
should also continue to pay premiums on the old policy/certificate until the new
policy/certificate is approved and delivered. If the insured lets the policy/certificate lapse
more than 30 days and is declined, denied, or rated under the new policy/certificate, the
insured will not be allowed to reinstate the old policy/certificate.
It is extremely important that ACMIC policy/certificate holders are aware they must disclose
pre-existing conditions. For example, if a policy/certificate holder developed an illness while
on their existing policy/certificate, ACMIC might exclude or apply a pre-existing condition
American Community Mutual Insurance Company
Rev. April 2005
1-6
Selecting the Correct Application
period to that illness for the replacement policy/certificate. Consequently, claims may be
denied on the replacement policy/certificate for that illness.
NOTE:
If a current ACMIC policy/certificate holder is issued a replacement
policy/certificate, and ACMIC denies a claim on their replacement
policy/certificate due to a pre-existing condition, ACMIC will not permit the
policy/certificate holder to change their coverage back to their prior
policy/certificate.
Reinstatement Applications
Reinstatement applications are used for any policy/certificate that has lapsed more than 31
days, but less than 12 months where the applicant wishes to apply for the same product,
deductible, coinsurance, and options as the original policy/certificate. Reinstatement
applications will be fully underwritten, and must be accompanied by at least two months’
premium. Policies/certificates that have lapsed more than 12 months cannot be reinstated; a
new formal application must be submitted.
Policies/certificates with premiums that are due and received at the Home Office during the
grace period (31 days) will be kept in-force without any need to reinstate. Premiums received
at the Home Office after the 31-day grace period cannot be accepted and will be returned.
State Uninsurable Health Insurance
Plans
To provide coverage for people who are unable to purchase satisfactory medical insurance
through private insurers, the following states have enacted State Health Plans or insurers of
last resort: Illinois, Indiana, Iowa, Michigan, and Nebraska. These plans pool expenses
among all the insurers who write medical insurance coverage in a given state. Individuals
who have been declined, charged an extra premium, or issued coverage with an exclusion
rider might be eligible to obtain coverage through these plans. However, ACMIC will only
notify those applicants that ACMIC has declined. Many states require insurers to notify
applicants of their eligibility to apply for coverage under these plans. All of the state
uninsurable plans are only available to applicants who have no current health coverage in
force.
Rev. April 2005
American Community Mutual Insurance Company
2 Writing Short-term
Applications
Short-term applications are an interim health insurance plan for individuals transitioning
from one permanent health plan to another. Short-term insurance is not intended to be of a
permanent nature and is not renewable or intended to be used as travel insurance. Because a
short-term policy/certificate is not subject to underwriting, the applicant is not considered to
be replacing coverage when moving to a permanent policy/certificate.
In Michigan, short-term policies/certificates can be written in any combination of terms so
long as the total period does not exceed six months in any 12-month period.
In Illinois, Indiana, Iowa, Missouri, Ohio, and Nebraska short-term policies/certificates can
be written in any combination of terms, as long as the total period of coverage does not
exceed 12 months. There must be a minimum 90-day period of no coverage before applying
for another short-term policy.
The applicant can determine the length of coverage by checking the box on the application
that corresponds to the number of months that they desire coverage.
Online Application
An online (electronic) application for short-term coverage is available. This is an efficient
and effective method of submitting a short-term application that results in faster policy
approvals. To complete a short-term application online, the agent can refer the client to the
agency Web site, presuming the link is set-up, or the agent can e-mail the link directly to the
client.
The client will complete the application online and it will be submitted to American
Community Mutual Insurance company (ACMIC). ACMIC staff will log in to the online
portal and retrieve the application. ACMIC will then process the final screening of the
application and enter the information into the Individual Administration System. The credit
card will be charged and then the approval will be issued online. This will initiate a written
approval letter to the client, including the effective date and the policy number.
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2-2
Writing Short-term Applications
For questions or assistance with online short-term applications, contact the National Sales
Office.
Eligibility
Short-term insurance is not underwritten. The applicant qualifies based on the accurate
response to the questions on the application. Any person who answers “yes” to any question
is ineligible for the issuance of a policy/certificate.
Short-term plans can be issued to people who:
Are less than 64 years of age and are not covered under any other medical expense plan.
Are not, nor is any dependant, pregnant.
Have not been declined for insurance due to health reasons.
Have not lived outside the United States, Australia, Canada, England, Ireland, Scotland,
or New Zealand within the last 12 months.
Have no health insurance coverage
Able to answer “no” to all parts of the questions concerning medical conditions and
alcohol or drug use.
Any applicant who answers “yes” to any question is ineligible for the issuance of a
policy/certificate. Other applicants will be eligible based on their individual responses.
Individuals who have health conditions or non-medical risks, which would cause them to be
declined for renewable health insurance should not be submitted for short-term coverage.
Signing the Application
The short-term policy/certificate application is part of the contract with ACMIC. By signing
the application, the applicant is representing that the information provided is true and
complete. The applicant is also attesting to the best of their understanding that:
Coverage becomes effective on the policy/certificate date and that no benefits are payable
for pre-existing conditions.
That the policy/certificate is not a renewal or extension of any other policy/certificate. If
an applicant has two short-term policies/certificates, injuries, or medical conditions under
the first policy/certificate are pre-existing under the second policy/certificate. Short-term
policies/certificates are not a renewal or extension of any previous coverage, and do not
cover any condition for which benefits were paid under a previous policy/certificate.
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American Community Mutual Insurance Company
Writing Short-term Applications
2-3
Electronic signatures on the online application are as binding as wet signatures on a
printed application.
NOTE:
Signature and date/time errors on the application cannot be corrected. A new
application must be completed. If an application is submitted with corrected
signatures or dates, the application will be returned without consideration.
NOTE:
All occurrences of an applicant’s name and their legal signatures must match.
Applicants must consistently use one name for each applicant (i.e., do not use
“Joe” in one part of an application and “Joseph” in another).
Required Signatures
If the applicant is paying by electronic funds transfer (EFT), their signature is required in
the “Authorization Information for Electronic Funds Transfer for Premium Payment”
panel. If the applicant is applying for a short-term policy online, the applicant must pay
the premium with a credit card.
The key applicant must sign page 1.
Spouses must sign page 1 if they are also seeking coverage under this policy/certificate.
Dependents 16 years and older (18 in MO) must sign page 1 if they are seeking coverage
under this policy/certificate. A parent or guardian must sign for children under age 16 (18
in MO).
Coordinating a Short-term Plan to a
Permanent Plan
If an applicant does not currently have coverage, it is advisable to complete an application for
a Short Term policy at the same time the application is completed for the permanent policy.
The Short Term policy should be written for 1 to 2 months when used as coverage for the
applicant to bridge them to the effective date of their permanent policy.
In order to obtain additional benefits when bridging from a Short Term policy to a permanent
policy, the applications for both the Short Term policy as well as the permanent policy must:
•
•
•
Be completed at the same time.
Be signed and dated at the same time.
Be submitted to American Community together with the premium for both policies
If the applicant has not received notice of the permanent policy approval at least two working
days prior to the end of the original Short Term policy, please contact Medical Underwriting
American Community Mutual Insurance Company
Rev. April 2005
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Writing Short-term Applications
to determine if a second Short Term policy needs to be submitted. If yes, then the second
policy must be postmarked no later than the day the current Short Term policy ends to
maintain continuous coverage.
If all requirements above are met and there has been continuous coverage with American
Community, American Community will provide a deductible carryover on the additional
Short Term policy, if needed, as well as the permanent policy. This means, for example, if
the applicant satisfied $200 of his deductible under the first Short Term policy, then the
second Short Term policy, if needed, as well as the permanent policy would have their
current deductible amount reduced by the $200.
In addition, if the requirements above are met, claims incurred under the Short Term policy
related to an injury or accident that first occurred after the effective date of the Short Term
policy will not be considered as pre-existing conditions under a subsequent, continuous Short
Term policy and/or permanent policy if the policy is issued.
Illnesses, disorders or conditions that occurred while covered under the Short Term coverage
must be reported to Underwriting for consideration in the underwriting process and for
determining the appropriate underwriting action which can include:
•
•
•
•
Issuing the policy as standard,
Rating for the condition,
Placing a rider for the condition, or
Declining to issue coverage because of the condition.
Premiums Payable
Commingling of funds is the placing of another’s money in any type of an account controlled
by the agent. This is strictly prohibited. All transactions involving the transfer of funds
should be handled accurately and promptly.
NOTE:
Under no circumstances can the agent pay any premiums for applicants. This
could be considered a form of rebate and is a violation of the law in most states.
NOTE:
ACMIC will not accept payments in cash, an agency check, or a check from the
agent. The applicant should be offered the option of paying by credit card,
electronic funds transfer (EFT), or check. An application submitted with cash by
the agent or applicant, cannot be accepted.
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American Community Mutual Insurance Company
Writing Short-term Applications
2-5
The applicant may pay the premium by check, money order, EFT, or credit card (initial
premium only). The Authorization for Electronic Funds Transfer must be completed to use
the EFT.
Selecting a Billing Option
Premiums can be paid monthly or by lump sum. A minimum of one month’s premium must
be submitted with any application.
Selecting a Payment Option
Initial premiums may be paid by personal check or money order, or charged to VISA or
MasterCard.
Paying by Check or Money Order
Only checks made payable to “American Community Mutual Insurance Company” will be
accepted. The agent should never accept checks that are made payable to “cash” or to the
agent from applicants or policy/certificate holders. ACMIC will not accept post-dated
checks.
When an applicant makes an initial remittance with the application, the full mode premium
should be included and noted on the application. When subsequent premium payments are to
be made by bank draft, the bank draft authorization form should be included along with a
voided check on the payer’s account.
Paying by Electronic Funds Transfer (EFT)
Electronic Funds Transfer (EFT) authorizes ACMIC to monthly draft the subsequent (not
initial) premiums on the applicant’s checking account. Agents must complete a Bank
Authorization Form whenever an applicant requests to pay their premium by EFT.
To begin EFT payments, the applicant must:
1. Complete all of the information in the “Authorization Information for Electronic Funds
Transfer for Premium Payment” panel on the second page of the application.
2. Submit the initial one or two months’ premium payment in the form of a check or credit
card authorization (VISA or MasterCard).
3. Submit a voided check (not a deposit slip) with the application.
Most banks need 12 to 14 calendar days from the initial setup before the first withdraw can
be made to complete an initial EFT. Therefore, it will be at least two weeks before ACMIC
can make its first withdrawal.
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Rev. April 2005
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Writing Short-term Applications
Paying by Credit Card
Select either Visa or MasterCard for payment. Write the credit card number legibly, leaving
spaces between each group of four numbers. Write the expiration date as mm/yy, i.e., 07/04
for July 2004.
NOTE:
Regular monthly premium payments cannot be made by credit card.
NOTE:
To prevent delays due to processing errors, do not submit the card number from a
debit card. Debit cards are not interchangeable with credit cards.
ACMIC will charge the credit card the full amount due to pay the policy/certificate to a
current status. This will result in no premium due notices being generated to cover the
remaining balance due, and reduce the time needed to activate these policies/certificates.
All online applications must be submitted with the information necessary to bill a credit card
for the premium due.
Agents who have questions may contact a customer service representative or the National
Sales Office.
Determining Effective Dates
For a short-term policy, the applicant can request an effective date of coverage if the
effective date is after the signature date. If no date is requested, the assigned effective date
will be the day after a legible postmark, the day after the application is received for
applications that are faxed, delivered in person, or the day following submission of an online
application. An effective date will not be assigned for the 29th, 30th, or 31st of the month.
If coordinating a short-term plan to a permanent plan, the effective date for the permanent
plan will be the day following the short-term termination date.
NOTE:
An effective date that is earlier than the date the application is signed cannot be
requested. Under no circumstances will an effective date be assigned prior to the
date the application is signed by all applicants.
Rev. April 2005
American Community Mutual Insurance Company
3 Completing Prescreen
Forms
Eligibility
Agents can use prescreen forms to quickly receive an underwriting assessment of risk based
on minimal medical information. These underwriting opinions are helpful to determine the
action that Medical Underwriting might take when faced with a particular set of
circumstances. For example: the interaction of multiple medical conditions that might be a
decline; or risk assessment for recurrent conditions, whether a condition can be rated or have
a rider added.
Completing a Prescreen Form
The prescreen form is one page long. A prescreen form can be completed entirely by an
agent, and does not require the applicant’s signature.
All prescreen forms for insurance are generalizations and tentative opinions, not to be taken
as a guarantee of final action. These opinions should not be communicated to applicants as
final decisions. Prescreen forms can be sent directly to an underwriter by fax, mail, or asked
by phone. Initial opinions are based on the information presented on the prescreen form.
Underwriters will not review medical records, issue questionnaires or memos, or order exams
unless a permanent application with the appropriate premium is received.
The name and date of birth for each applicant must be provided to complete the prescreen
form. Providing the plan choice and recommended deductible is necessary for the
underwriter to provide an estimated rating.
To get the most accurate opinion, agents should obtain as much information as possible from
the applicant, including:
Height and weight.
Smoking status.
Impairment or medical condition history.
Date of initial symptoms.
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3-2
Completing Prescreen Forms
Date of the last occurrence.
Duration of the condition.
Final results of treatment.
Medication or treatment prescribed or administered.
Medical Underwriting will inform agents by fax or phone if the applicant would qualify for
insurance, and if a rider or rating would be required. Underwriters will also provide an
estimate of whether a minimal, moderate, or high rating would be assessed.
If, after receiving a prescreen response, an agent submits a permanent application, the agent
must attach a copy of the completed prescreen form. This alerts the underwriter that a
tentative opinion has been given, which will reduce the time needed for the underwriting.
Agents who have questions may contact a customer service representative or the National
Sales Office.
Rev. April 2005
American Community Mutual Insurance Company
4 Writing Permanent
Applications
Eligibility and Schedule of Persons
Proposed for Insurance
Permanent policies/certificates are used for applicants who are an acceptable risk, and who
want insurance coverage for at least one year. All permanent policies/certificates are subject
to underwriting.
When an agent believes a prospective applicant is an acceptable risk, the agent should obtain
a written formal application for insurance. The agent should also obtain the appropriate state
required forms. Refer to the appendices for listings of approved applications, underwriting
requirements, and replacement forms.
Agents must be licensed in the state(s) where they solicit business prior to becoming
appointed by American Community Mutual Insurance Company (ACMIC). Only agents
licensed in the state will be allowed to solicit and submit business for ACMIC.
NOTE:
Applications cannot be solicited, taken, or dated prior to the agent’s appointment
to represent ACMIC. Commission cannot be paid on business solicited prior to an
appointment.
Only the key applicant, their spouse, and any unmarried children who are at least 15-days
old and have not yet reached their 22nd birthday, can be included on the application.
Children, stepchildren, and legally adopted children who are legally dependent on the
applicant are eligible for coverage.
Divorced spouses are not eligible under the key applicant. They must submit a separate
application.
Grandchildren who are in the legal custody of their grandparents can be added to a
grandparents’ policy/certificate if they are legally dependent on their grandparents.
Grandchildren are subject to underwriting. The grandparents must provide copies of their
guardianship papers.
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Rev. April 2005
4-2
Writing Permanent Applications
Applications can be completed to insure children without either parent being on the
application. The child must be at least 15-days old and less than 18-years old to apply.
The legal parent must sign the application. The front of the application (page 1 Section B)
must be marked “New Application for Children Only”. For a single child
policy/certificate, the premium is charged at the youngest adult male rate regardless of
the gender of the child. For child-only policies/certificates with multiple children
applying, the youngest child becomes the key applicant, and is charged the youngest
adult male rate, regardless of the gender of the child. All other children are charged child
rate.
NOTE:
Dependents can be added to a policy/certificate by completing a permanent
application. To add a female spouse, the maiden name and any previous married
names must be listed. Adding a spouse, and children other than newborn and
adopted, are subject to underwriting.
General Guidelines
1. Applications for health insurance should be entirely completed by all the applicants. An
applicant might require assistance from an agent to answer questions regarding
replacement of prior insurance, HIPAA portability and privacy, medical questions, etc.
2. Agents are responsible for transmitting accurate, pertinent, and complete information
about the applicant to ACMIC. Agents must ensure that the application is accurately and
totally completed.
3. Agents must ask all questions on the application as they are written; do not paraphrase or
generalize.
4. Agents must not make a determination whether an applicant should report a condition. If
the applicant mentions a condition, the agent must record it. Medical Underwriting will
determine the significance of a condition.
5. Agents must ensure that complete answers are documented and not omit any medical or
demographic information. Omitting information or altering the application in any way,
raises questions as to the legality of the contract. Omitting information could subject an
agent to a professional liability claim.
6. Applications that are not taken in person may be completed over the phone with
signatures secured, in person, after the call. Agents must still review applications with the
applicant to ensure that accurate information has been recorded.
7. All written answers on the application must be in the applicant’s handwriting and legibly
printed in black ink. A dash or “N/A” will not be accepted as appropriate answers.
8. Applicants who cannot read and understand English or have a physical disability can be
assisted by interpreters to apply for insurance. The interpreter must document in written
form that the applicant has been fully advised of the application contents.
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American Community Mutual Insurance Company
Writing Permanent Applications
4-3
Provide proposal
Sign and date
the application
E
Corrections
required
N
Y
Date or
signature
error?
Y
N
Give
notifications to
the applicant
Line out error,
print correction,
applicant initials
Shred
application,
begin again
9. To change an answer on an application, the applicant (not the agent) must make the
correction by drawing a single line through the incorrect answer and printing the correct
response above the incorrect answer. The applicant (not the agent) must then initial and
date the corrected change. Using whiteout and correction tape is unacceptable.
NOTE:
Signature and date errors on the application cannot be corrected. A new
application must be completed. If an application is submitted with corrected
signatures or dates, the application will be returned without consideration.
10. Agents are responsible for reviewing the application for completeness before sending it to
the Home Office. Incomplete applications and/or applications not signed by the writing
agent will not be accepted.
11. Applications must be received at the Home Office within 30 days of the date the
application was signed. Because the application might not accurately reflect the health
American Community Mutual Insurance Company
Rev. April 2005
4-4
Writing Permanent Applications
status of the applicant, applications received more than 30 days after the signed date will
be returned.
12. Applications are void if not approved within 90 days. A new application must be
completed and signed by the applicant. All applicants will receive notification of the
status of their application 45 days from the date the application is entered into the
Individual Administration System.
13. The agent’s signature is required on the Agent’s Certification section of the application.
This must be the signature of the agent who actually solicited the business and assisted
the applicants in completing the application.
Existing Coverage and Replacement
Applications should not be submitted if any in-force health insurance is not being replaced,
cancelled, or terminated. ACMIC policies/certificates are designed and priced to provide
standalone protection. Over-insurance situations cannot be approved, and the application will
be returned to the applicant.
To speed the underwriting process, it is necessary to give all information regarding the
current policy/certificate being replaced. This must include the company name,
policy/certificate number, type of insurance, and effective dates.
Some states have special notice requirements when existing health insurance is to be replaced
(i.e., Illinois or Iowa). Replacement notices must be completed at the point of sale and copies
forwarded to ACMIC with the application. Applications submitted without the appropriate
replacement forms will be returned to the agent. Because these notices are designed to assist
the applicant in understanding the positive and negative aspects of replacing a
policy/certificate, these notices cannot be secured on delivery.
An applicant who plans to replace coverage should be informed by the agent not to cancel or
cease paying regular premiums on existing insurance until the new ACMIC policy/certificate
is approved and delivered.
Health Insurance Portability and
Accountability Act (HIPAA)
The Health Insurance Portability and Accountability Act, and some state laws, require
insurance carriers or state sponsored plans to offer coverage to eligible individuals. This
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American Community Mutual Insurance Company
Writing Permanent Applications
4-5
means that the eligible individual cannot be declined coverage, and will be issued a
policy/certificate without pre-existing condition exclusion. When required by law, ACMIC
will offer coverage to an eligible individual. The policy/certificate is rated as any nonHIPAA policy/certificate would be rated. There is no penalty for an individual in seeking a
HIPAA policy/certificate.
An eligible individual must meet all of the following:
On the date of applying for coverage with ACMIC, the applicant has 18 months or more
of Credible Coverage as defined below without any breaks of 63 days or more;
o Credible Coverage includes coverage under a group health plan, health insurance
coverage, Medicare, Medicaid, 10 U.S.C.55 plans for certain members of the Armed
Forces, Indian Health services or a tribal organization, public health plans, the
Federal Employees Health Benefits Program; state health benefits risk pool; Church
plan, or Peace Corps plan.
Most recent prior Credible Coverage was under a group health plan, governmental plan,
or church plan.
Does not have other health insurance coverage.
Has no right to other insurance such as another group health plan, Medicare, Medicaid,
COBRA, or continuation coverage under a state plan. If the individual was offered
COBRA or state continuation plan, they must have elected and exhausted the coverage;
The most recent Credible Coverage was not terminated for nonpayment of premium or
fraud.
The benefits of a HIPAA policy/certificate should be carefully explained to the applicant,
especially if they have pre-existing medical conditions or have a condition that would be
an underwriting decline. If it is determined that a HIPAA policy/certificate is needed
based on the individual’s circumstances, the agent should direct the client appropriately.
States determine the implementation of HIPAA.
AZ Agents must note on the front of the application that the applicant is seeking a
HIPAA policy/certificate. Page 1, section B of the application asks the applicant to
indicate the type of application being submitted and this must indicate a HIPAA
Policy. Page 2 section D, question 5 confirms that the applicant is requesting a
HIPAA policy and indicates the form that is required to accompany the application.
This form is ACMIC’s HIPAA Certification form 580-SUPP-APP AZ,
documenting 18 months of prior insurance Credible Coverage with no breaks of 63
days or more and proof of Credible Coverage from the prior carrier.
IL Agents must direct applicants to the Illinois Comprehensive Health Insurance Plan
IN Agents must direct applicants to the Indiana Comprehensive Health Insurance Plan
IA Agents must direct applicants to the Iowa Comprehensive Health Insurance Plan
MI Agents must direct applicants to the insurer of last resort.
MO Agents must note on the front of the application that the applicant is seeking a
HIPAA policy/certificate. Page 1 section B of the application asks the applicant to
American Community Mutual Insurance Company
Rev. April 2005
4-6
Writing Permanent Applications
indicate the type of application being submitted and this must indicate a HIPAA
Policy. Page 2 section D, question 5 confirms that the applicant is requesting a
HIPAA policy and indicates the form that is required to accompany the application.
This form is ACMIC’s HIPAA Certification form 580-SUPP-APP, documenting 18
months of prior insurance Credible Coverage with no breaks of 63 days or more and
proof of Credible Coverage from the prior carrier.
NE Agents must direct applicants to the Nebraska Comprehensive Health Insurance
Plan.
OH Agents must note on the front of the application that the applicant is seeking a
HIPAA policy/certificate Page 1 section B of the application asks the applicant to
indicate the type of application being submitted and this must indicate a HIPAA
Policy. Page 2 section D, question 5 confirms that the applicant is requesting a
HIPAA policy and indicates the form that is required to accompany the application.
This form is ACMIC’s HIPAA Certification form 580-SUPP-APP documenting 18
months of prior insurance Credible Coverage with no breaks of 63 days or more and
proof of Credible Coverage from the prior carrier.
Premiums Payable
Commingling of funds is the placing of another’s money in any type of an account controlled
by the agent. This is strictly prohibited. All transactions involving the transfer of funds
should be handled accurately and promptly.
NOTE:
Under no circumstances can the agent pay any premiums for applicants. This
could be considered a form of rebate and is a violation of the law in most states.
NOTE:
ACMIC will not accept payments in cash, an agency check, or a check from the
agent. The applicant should be offered the option of credit card, electronic funds
transfer (EFT), or check. An application submitted with cash, by the agent or
applicant, cannot be accepted.
The applicant may pay the premium by check, money order, EFT, or credit card. The
Authorization for Electronic Funds Transfer must be completed to use the EFT.
Premium payments must always be submitted with health applications. Applications
submitted without a premium payment will be returned to the agent, except if the application
is being made to add individuals to an in-force policy/certificate or for rewriting a current
ACMIC plan.
When an initial remittance is made by the applicant with the application, the full mode
premium should be included and noted on the application. When subsequent premium
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American Community Mutual Insurance Company
Writing Permanent Applications
4-7
payments are to be made by bank draft, the bank draft authorization form should be included,
along with a voided check on the applicant’s account. Two months' premium should be
submitted with the application when submitting on EFT basis to avoid a higher premium
delivery requirement.
Selecting a Billing Option
Premiums can be paid monthly, quarterly, semi-annually, annually, by EFT, or by list bill. A
minimum of one month’s premium must be submitted with any application. Premiums made
payable monthly will be charged a monthly $4.75 Administration Fee.
Selecting a Payment Option (non-List Bill)
Initial premiums may be paid by personal check, money order, charged to VISA or
MasterCard, or by EFT.
Paying by Check or Money Order
Only checks made payable to “American Community Mutual Insurance Company” will be
accepted. Agents should never accept checks that are made payable to “cash” or to the agent
from applicants or policy/certificate holders. ACMIC will not accept post-dated checks.
When an applicant makes an initial remittance with the application, the full mode premium
should be included and noted on the application. When subsequent premium payments are to
be made by bank draft, the bank draft authorization form should be included along with a
voided check on the payer’s account.
Paying by Credit Card
NOTE:
The regular monthly premium payments cannot be made by credit card. ACMIC
can accept credit card payments for the initial premium payment and/or any
balance due on delivery.
Select either Visa or MasterCard to pay for the initial premium or balance due on delivery.
Write the credit card number legibly, leaving spaces between each group of four numbers.
Write the expiration date as mm/yy, i.e., 07/04 for July 2004.
ACMIC will charge the credit card the full amount due to pay the policy/certificate to a
current status. This will result in no premium due notices being generated to cover the
remaining balance due, and reduce the time needed to activate these policies/certificates.
An option to pay any balance due with a credit card will now be included with the premium
due notice sent with policies/certificates. Space will be available for the credit card number,
expiration date, and cardholder signature. The insured will have the option of paying the
balance due by check, money order, or credit card.
American Community Mutual Insurance Company
Rev. April 2005
4-8
Writing Permanent Applications
Agents who have questions may contact a customer service representative or the National
Sales Office.
Paying by Electronic Funds Transfer (EFT)
Electronic Funds Transfer (EFT) authorizes ACMIC to monthly draft the premium on the
applicant’s checking account. Agents must complete a Bank Authorization Form whenever
an applicant requests to pay their premium by EFT. A new authorization form is not required
if existing business is already on the EFT payment plan.
To begin EFT payment, the applicant musts:
1. Complete all of the information in Part I Section F.
2. The initial premium, any balance as well as subsequent monthly premiums can be set up
for EFT payment.
3. Alternatively, applicants can pay the initial two months’ premium payment in the form of
a check or credit card authorization (VISA or MasterCard). The balance and subsequent
premiums can be paid by EFT, or additional premiums might be required upon delivery
of the policy/certificate to bring the new policy/certificate to a current paid status.
4. Submit a voided check (not a deposit slip) with the application.
Most banks need 12 to 14 calendar days from the initial setup before the first withdrawal can
be made to complete an initial EFT. Therefore, it will be at least two weeks before ACMIC
can make its first withdrawal.
Paying by List Bill
List bills are individual health policies/certificates being billed on one billing notice to an
employer. All individual policies/certificates have a common billing date.
In accordance with applicable law, employers who provide list-billing service for employees
who purchase products marketed to individuals cannot contribute in any way towards the
employee's health insurance premium.
Requirements for Creating a List Bill:
List bills must have a minimum of three (3) policies/certificates.
The request must be in writing.
The request must have the name, address, and phone number of the employer, contact
person, and the company’s fax number.
The request must have names and policy/certificate numbers of each insured to be billed.
All policies/certificates must be paid current.
No application for a list bill will be accepted without a signed List Bill Agreement.
Each applicant must complete the Request for Monthly Premium Deduction from Salary
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American Community Mutual Insurance Company
Writing Permanent Applications
4-9
Adding a New application to a List Bill:
Submit two months’ premium with the application.
There will be a $10.00 per month Administration Fee for all list billings.
Verify the billing date of the existing list bill and have the new policy/certificate effective
that date.
Submit list billing forms.
o The List Bill Agreement is not needed if applicant(s) are being added to an existing
list bill;
o Request for Employer Deduction Form is needed
Reminders:
New policies/certificates will not show on the list bill until all delivery requirements are
received.
If all policies/certificates are not paid to the same date this could cause the unpaid
policies/certificates to drop off the list bill, causing the unpaid policies/certificates to
lapse.
When an employer pays by check, they must include their Billing Notice, to ensure the
correct posting of the check.
If the employer notices that a policy/certificate has been dropped from the list bill, they
should contact Customer Service.
Removing a Policy/certificate From a List Bill
The request must be in writing.
If the policy/certificate is to be cancelled, ACMIC needs the request to be in writing by
the individual insured. ACMIC cannot accept a request from the employer to cancel a
policy/certificate/certificate because these are individual policies/certificates, and must be
cancelled by the insured.
The ACMIC List Billing Agreement and Request for Deduction of Monthly Premiums from
Salary forms must be received at the time of application. With the initial application and
request to establish a list billing number, the agent and the employer must sign the List
Billing Agreement Form. The original, signed form must be forwarded to American
Community Mutual Insurance Company, Individual Underwriting Department.
Employers should be advised to give a copy of the Request for Deduction of Monthly
Premiums from Salary form to each of their employees along with their applications for
health coverage. As each employee applies for individual health insurance, a copy of the
Request for Deduction of Monthly Premiums from Salary must be signed by the applicant
and attached to the application.
NOTE:
Because these forms are used to ensure compliance with the law, no application
will be accepted without the signed forms.
American Community Mutual Insurance Company
Rev. April 2005
4-10
Writing Permanent Applications
Agents may obtain additional forms by downloading them from the ACMIC Web site
(www.american-community.com), or by faxing the Supply Area. Agents who have questions
may contact a customer service representative or the National Sales Office.
Plan of Health Insurance
To accurately underwrite the policy/certificate and issue the correct documents, applicants
must select a plan of insurance, deductible, co-pay, and options. Only plans listed on the
application can be selected. For the HSA product, place an “X” in the appropriate boxes on
page 4 and complete the addendum form. Because the form is part of the application, it must
be secured with the application.
NOTE:
The applicant must select a PPO network at the time of application. To assist the
applicant in determining if their provider is in the network, PPO member
directories are available on the ACMIC Web site
(www.american-community.com).
Contraceptive Coverage Opt-Out
Some states allow applicants to waive coverage of contraceptive pills, methods, or devises if
these conflicts with the applicant’s moral, ethical, or religious beliefs. To waive this coverage
in Missouri, the applicant must initial the waiver statement in on page 4 Section G.
Non-Medical Underwriting Questions
Each question applies to each individual applicant. For risk factors related to non-medical
conditions, such as occupations, avocations, and foreign-travel or residence, refer to Chapter
7 – “Risk Selection”.
Part II - Medical History
All permanent health insurance applicants are individually underwritten. Therefore, each
question applies to each individual applicant. Because benefits will be paid for all fully
disclosed medical conditions that are not excluded from coverage by the policy/certificate or
by rider, it is very important that the applicant provide as much information as possible.
For all conditions listed, details must be given on page 6 of the application and the physician
providing treatment listed on page 8. This must include the name of the person with the
Rev. April 2005
American Community Mutual Insurance Company
Writing Permanent Applications
4-11
condition, the physician’s name and address, medications, tests, beginning and ending dates
of treatment, and any surgery/procedure/treatments. For each physician named, an
Authorization to Obtain Protected Health Information must be obtained.
NOTE:
If the agent has already submitted a prescreen form, the agent must submit it with
the permanent application. This alerts the underwriter that a tentative opinion has
been given, which will reduce the time needed for the underwriting.
Underwriting determinations are made based on the risk that each individual presents to
ACMIC. The underwriter is responsible for accurately assessing the risk. Individual medical
conditions and social factors might combine to increase the risk the individual presents. For
example, smoking in the presence of someone with asthma. Refer to Chapter 7 – “Risk
Selection” for possible underwriting determinations.
Determining Effective Dates
NOTE:
•
A request for an effective date that is earlier than the date the application is signed
cannot be granted. Under no circumstances will an effective date be assigned
prior to the date the application is signed by all applicants.
An effective date can only be requested if the applicant is replacing permanent coverage,
are qualified under HIPAA, or are ending COBRA. Because all permanent
policies/certificates are underwritten and coverage might not be offered as applied for,
the active policy/certificate should not be allowed to lapse.
If the applicant is replacing ACMIC coverage that is in-force, the future effective date
will be the paid-to date-of the policy/certificate being replaced. Because the replacing
policy/certificate is fully underwritten and coverage might not be offered as applied for,
all premiums should be paid on the in-force policy/certificate when due. The in-force
policy/certificate should not be allowed to lapse.
If the applicant does not have present, permanent coverage, an effective date cannot be
requested. The policy/certificate effective date will be assigned by ACMIC and will not
be sooner than 30 days from the signature date or the underwriting decision date,
whichever is the latter. Because short-term policies/certificates are not underwritten, they
are not considered as replacing a policy/certificate.
When the applicant has been offered quote options (i.e., a rating or a rider), the effective
date will be the date the quote is accepted by the applicant or 30 days from the signature
date, which ever is the latter.
An effective date will not be assigned for the 29th, 30th or 31st of the month.
American Community Mutual Insurance Company
Rev. April 2005
4-12
Writing Permanent Applications
C
Y
Replacing
long-term
coverage?
N
Y
Replace
existing
ACMIC?
Y
N
Effective date =
paid-to-date of
current policy
Qualified
under
HIPAA?
Y
N
Ending
COBRA?
Y
N
Effective date
assigned by
ACMIC > 30
days
Effective date
assigned per
request or paidto-date of the
current policy
D
For cases replacing coverage if no special effective date is requested on the application, the
effective date of coverage will be:
The underwriting approval date, or;
If a rated premium or modified policy/certificate is quoted, the effective date will be the
date the quote is accepted in writing by the applicant as communicated to the agent.
If the applicant is replacing coverage now in-force, it is recommended to request a future
effective date of at least 30 to 60 days from the application date, but no more than 90
days from the date of signing. After an effective date is requested on the application, it
will not be changed unless a quote for special class (rated) or modified insurance (family
member declined or exclusion rider offered) is accepted by the applicant (by way of the
agent) in writing. The quote offer will allow the applicant to request a different effective
date. This date cannot be more than 90 days from the date the application was signed.
Rev. April 2005
American Community Mutual Insurance Company
Writing Permanent Applications
4-13
Not taken, canceled, or incomplete cases that are resubmitted with a new application for new
underwriting simply to secure a new effective date will not be accepted. Within six months
from the original application date, a new policy/certificate for a different product may be
requested. Requests for new policy/certificate plans require a new application and full
underwriting.
Declarations and Consents
By signing the application, the applicant is agreeing to allow ACMIC to query providers,
databases, pharmacies, etc. These queries are initiated at the discretion of the underwriter.
The applicant also agrees that ACMIC may obtain consumer reports for such conditions as:
DWI or DUI admitted on the application.
Anyone suspected of not being a US permanent resident.
Past alcohol abuse or abuse of non-prescription or prescription drugs.
Past criminal activity.
Past financial difficulty.
Suspected hazardous occupations or avocations.
Change in Health Status
Directly above the applicant's signature on page 7 is a statement that requires the applicant to
notify ACMIC if the answers to the questions on the application do not continue to be true, or
the answers have changed due to a change in health prior to delivery of the policy/certificate.
This statement ensures that ACMIC has information regarding changes of an applicant's
health status during the underwriting period.
For the purpose of reporting changes in health status, ACMIC will consider this requirement
fulfilled if the applicant notifies ACMIC of changes prior to when the policy/certificate is
mailed. The date and time of mailing will be indicated by the postmark on the envelope in
which the policy/certificate is sent. This does not, however, change the terms of the
policy/certificate or the conditions under which the policy/certificate becomes effective.
Those conditions are outlined on the front of the application.
American Community Mutual Insurance Company
Rev. April 2005
4-14
Writing Permanent Applications
Trust Participants
In some states, the ACMIC products have been filed with the state as part of a group trust.
One of the requirements of entering the trust is that the key applicant request to participate.
To request participation, and to ensure that the applicant understands that they are subject to
the terms of the trust and subject to a group master policy/certificate, the key applicant must
sign the trust agreement. In those states where products are sold under a trust, no application
will be accepted unless the Trust Request to Participate has been signed by the key applicant.
Part III - Authorization to Obtain PHI
As a result of HIPAA privacy regulations, providers of health care are requiring an
authorization signed by the individual patient before medical information can be released.
The authorization on page eight is designed to meet all of the provider’s requirements for
release of plan of health insurance (PHI). For any medical condition listed on the application,
it is necessary that each individual applicant complete the authorization.
The key applicant, spouse, and any dependents over the age of 16 (18 in Missouri) who have
listed any medical conditions must complete Part III. This requires that the provider’s
(physician, facility, etc) name, address, and phone number be given at the top of the page.
Each individual must then sign the authorization at the bottom of the page. A parent or
guardian can sign for children under age 16 (18 in Missouri). The authorization must be
dated to be valid. To assist the provider in identifying the correct patient, the social security
number and date of birth is required.
Required Notices to Applicant
Three notices must be presented to the applicant when the application is completed:
Notification of Investigation (Declarations and Consent page)
Notice of Insurance Information Practices (if on state specific application)
A Summary of Your (Privacy) Rights (yellow copy of page 8)
HIPAA privacy regulations also outline the applicant’s rights regarding Protected Health
Information, and required that each applicant be given a copy of these rights. To assist the
agent in fulfilling this responsibility, a complete Notice of Privacy Rights is contained on the
back of the yellow copy of the authorization. Even if the applicant did not have to complete
the authorization, the yellow copy must be detached and given to the applicant.
Rev. April 2005
American Community Mutual Insurance Company
Writing Permanent Applications
4-15
Signing the Application
The matter of signatures is extremely important. The health insurance business is based on
legal and permanent contracts. ACMIC must be able to depend on the authenticity of every
signature that is supposed to be that of the person signing.
Agents are responsible for reviewing applications for completeness before sending them to
the Home Office. Incomplete applications and/or not signed by the writing agent will not be
accepted.
NOTE:
Signature and date/time errors on the application cannot be corrected. A new
application must be completed. If an application is submitted with corrected
signatures or dates, the application will be returned without consideration.
NOTE:
All occurrences of an applicant’s name and their legal signatures must match.
Applicants must consistently use one name for each applicant (i.e., do not use
“Joe” in one part of an application and “Joseph” in another).
Agents may never ask or permit an applicant to sign an undated, blank form. This
practice is unacceptable.
Agents are not allowed to sign for any applicant and should never sign forms on behalf of
clients to accommodate their needs. This practice is not permitted.
Signatures are to be written and must be legible.
Spouses are not allowed to sign for each other.
All applicants age 16 and over (18 and over in Missouri) are required to sign the
application. Parents and guardians may only sign for minor children.
Stamped signatures are not acceptable.
The agent’s signature is required in the Agent’s Certification section on the application.
No application will be accepted without the agent’s signature and the signature date.
Two signatures are required for credit card payments on page 3.
If the applicant is paying by EFT, their signature is required for Part I Section F.
The key applicant must sign Part II Section G.
Spouses must sign Part II Section G if they are also seeking coverage under this
policy/certificate.
Dependents 16 years and older (18 in Missouri) must sign Part II Section G if they are
seeking coverage under this policy/certificate. A parent or guardian may sign for children
under age 16 (18 in MO).
The agent must sign Part II Section G.
American Community Mutual Insurance Company
Rev. April 2005
4-16
Writing Permanent Applications
Application Preparation and Proper
Completion
There are several ways to compromise the integrity of the application that can create
potentially dangerous situations for ACMIC and its agents. Segmenting the application is one
such issue. Segmentation occurs when an applicant fills out an application in parts without
access to the total document. Segmentation can put an agent’s E&O insurance at risk and/or
the application could be considered falsified.
Problematic situations include, but are not limited to, illegibility, improper corrections, or
alterations and falsification of signatures. The following are examples of some of these:
Segmentation: An agent accepts a completed application and faxes it to ACMIC. The
agent fails to follow-up on the quote after it is generated but, in talking to the applicant by
phone, finds the applicant is still interested in purchasing insurance. The agent completes
a new application and submits it with the signature page from the previous application. If
there has been any change in the applicant's health or they are now on medication, it
would not be on the new application.
Segmentation: An agent completes an application over the phone and only faxes the
applicant page 7 (or the Declaration and Consent page) to sign.
Improper correction or alteration: An agent or applicant makes an error on the
application and uses "white-out" to cover the mistake.
Improper correction or alteration: The applicant makes an error and crosses it out with
a marking pen and attempts to enter the correct information.
Falsification of signatures: Father applies for coverage for wife and two children, both
attending college. The wife signs for both children as they are out of town.
Falsification of signatures: The applicant forgot to sign the Trust section, so the agent
signs it for his client.
In each of these cases, ACMIC is at risk when it accepts an application that is known to be or
suspected was not completed and signed by the applicant with all parts in front of them.
Because this is an unwise business practice and in some cases fraudulent, ACMIC routinely
returns these applications.
To ensure all submitted applications are complete and accurate:
ACMIC does not accept applications, which are known to be or suspected were not
completed at one time, as a total document.
When ACMIC has difficulty with one page of the application, the agent will not be
allowed to fax that page separately. This means that faxed pages will not be accepted
unless ACMIC believes that an amendment can provide the necessary protection for
ACMIC.
Rev. April 2005
American Community Mutual Insurance Company
Writing Permanent Applications
4-17
ACMIC will not accept any application where ACMIC has any doubts about the
authenticity of the signature.
American Community Mutual Insurance Company
Rev. April 2005
4-18
Writing Permanent Applications
Rev. April 2005
American Community Mutual Insurance Company
5 Writing Reinstatement
Applications
Eligibility
Premiums that are not received before the grace period ends will result in the termination of
the policy/certificate. Premiums that are due and received during the grace period can be
accepted without evidence of insurability and the policy will be kept in force. If the premium
was not received within the grace period, evidence of insurability is required in the form of
an Application for Reinstatement. If the American Community Mutual Insurance Company
(ACMIC) approves the application, the reinstated policy/certificate will be effective on the
day the reinstatement application was signed. ACMIC has 45 days from the date the
reinstatement application was received to render a decision to approve or disapprove
reinstatement. If the decision has not been made or communicated by the 45th day, the
policy/certificate will be reinstated.
The reinstated policy/certificate will cover only loss that results from an injury that occurs
after the reinstatement date or a sickness that occurs more than ten days after that date. In all
other respects, the applicant’s rights and ACMIC’s will remain the same, subject to any
provisions noted or attached to the reinstated policy/certificate.
Premiums that are due and received at the Home Office during the grace period (31 days)
without evidence of insurability will keep the policy/certificate in force (without any need
to reinstate).
Premiums not received at the Home Office within the 31-day grace period noted above
cannot be accepted without evidence of insurability in the form of an Application for
Reinstatement.
Policies/certificates that are lapsed for 12 months or less can be considered for
reinstatement if an Application for Reinstatement is submitted with at least two months
premium.
Policies/certificates lapsed more than 12 months cannot be reinstated and a new formal
application is required.
Premiums are due from the premium due day of the month in which the application for
reinstatement is dated and signed.
American Community Mutual Insurance Company
Rev. April 2005
5-2
Writing Reinstatement Applications
When an agent believes a prospective applicant is an acceptable risk, the agent should obtain
a written formal application for insurance. The agent should also obtain the appropriate state
required forms. Refer to the appendices for listings of approved applications, forms, and
underwriting requirements.
To reinstate a policy, the Application for Reinstatement must be completed and submitted
with at least two months premium. The application is subject to underwriting and might be
approved, declined, rated or a rider added based on the Underwriting Guidelines and the
underwriter’s determination.
If the application is accepted, premiums are due from the premium due day of the month in
which the application for reinstatement is dated and signed.
NOTE:
The HA-1 cannot be used as a reinstatement application. The reinstatement form
numbers are:
Arizona
Illinois
Indiana
Iowa
Michigan
Missouri
Nebraska
Ohio
33-27-H-AZ 6/03
33-27-H-IL 6/03
33-27-H 6/03
33-27-H-IA 1/05
33-27-H-MI 6/03
33-27-H-MO 6/03
33-27-H 6/03
33-27-H 6/03
Agents may order Reinstatement Applications from the ACMIC Web site
(www.american-community.com) or by faxing the National Sales Office.
The reinstated policy will only cover losses that result from an injury that occurs after the
reinstatement date or a sickness that occurs more than ten days after that date. No coverage is
available for conditions which pre-exist the date of the reinstatement application or which
appear (make themselves known) during the ten days after the date of the reinstatement
application. The contestable period begins on the reinstatement date.
In all other respects, the applicant’s rights and that of ACMIC will remain the same, subject
to any provisions noted or attached to the reinstated policy.
Agents that have questions may contact their customer service representative or the National
Sales Office.
Rev. April 2005
American Community Mutual Insurance Company
Writing Reinstatement Applications
5-3
General Guidelines
1. Applications for health insurance should be entirely completed by all the applicants. The
applicants might require assistance from the agent to answer questions.
2. Applicants must not omit any medical or demographic information. Omitting information
or altering the application in any way, raises questions as to the legality of the contract.
Omitting information could subject an agent to a professional liability claim.
3. All written answers on the application must be in the applicant’s handwriting and legibly
printed in black ink. A dash or “N/A” will not be accepted as appropriate answers.
4. Applicants who cannot read and understand English or have a physical disability may be
assisted by interpreters to apply for insurance. The interpreter must document in written
form that the applicant has been fully advised of the application contents.
Provide proposal
Sign and date
the application
E
Corrections
required
N
Y
Date or
signature
error?
Y
N
Give
notifications to
the applicant
Line out error,
print correction,
applicant initials
Shred
application,
begin again
American Community Mutual Insurance Company
Rev. April 2005
5-4
Writing Reinstatement Applications
5. Changes to answers on the application can be corrected by the applicant drawing a single
line through the incorrect answer and printing the correct response above the incorrect
answer. The applicant (not the agent) must then initial and date the corrected change.
6. Applications must be received at the Home Office within 30 days of the date the
application was signed. Because the application might not accurately reflect the health
status of the applicant, applications received more than 30 days after the signed date will
be returned.
7. Applications are void if not approved within 90 days. A new application would need to
be completed and signed by the applicant.
NOTE:
Signature and date errors on the application cannot be corrected. A new
application must be completed. If an application is submitted with corrected
signatures or dates, the application will be returned without consideration.
Schedule of Persons Proposed for
Insurance
Only the key applicant, their spouse, and any unmarried children who are at least 15 days
old and have not yet reached their 22nd birthday and were on the original policy when it
lapsed can be included on the application.
New applicants cannot be added to a reinstatement application. A new permanent
application must be submitted.
Applicants can be removed by submitting a letter that lists the people to be removed.
Applicants must provide the name and birth date as they appear on the permanent
policy/certificate.
Medical and Non-medical
Underwriting Questions
All health insurance applicants are individually underwritten. Therefore, each question
applies to each individual applicant. Because benefits will be paid for all fully disclosed
medical conditions that are not excluded from coverage by the policy/certificate or by rider,
it is very important that the applicant provide as much information as possible.
For all conditions listed, details must be given on page 1 of the application. This must include
the name of the person with the condition, the physician’s name and address, medications,
tests, beginning and ending dates of treatment, and any surgery/procedure/treatments. For
Rev. April 2005
American Community Mutual Insurance Company
Writing Reinstatement Applications
5-5
each physician named, an Authorization to Obtain Protected Health Information must be
obtained.
Determining Effective Dates
NOTE:
An effective date that is earlier than the date the application is signed cannot be
requested. Under no circumstances will an effective date be assigned prior to the
date the application is signed by all applicants.
When an application to reinstate is approved, the effective date of reinstatement is the date
the application is signed. Once approved, coverage for accidents is effective the date of the
reinstatement application; coverage for sickness is effective beginning ten days after the
reinstatement application date.
No coverage is available for conditions which pre-exist the date of the reinstatement
application or which appear (make themselves known) during the ten days after the date of
the reinstatement application.
Signing the Application
The matter of signatures is extremely important. The health insurance business is based on
legal and permanent contracts. ACMIC must be able to depend on the authenticity of every
signature that purports to be that of the person signing.
Agents are responsible for reviewing applications for completeness before sending them to
the Home Office. Incomplete applications or applications not signed by the writing agent will
be returned.
NOTE:
Signature and date/time errors on the application cannot be corrected. A new
application must be completed. If an application is submitted with corrected
signatures or dates, the application will be returned without consideration.
NOTE:
All occurrences of an applicant’s name and their legal signatures must match.
Applicants must consistently use one name for each applicant (i.e., do not use
“Joe” in one part of an application and “Joseph” in another).
Agents must never ask or permit an applicant to sign an undated, blank form. This
practice is unacceptable.
American Community Mutual Insurance Company
Rev. April 2005
5-6
Writing Reinstatement Applications
Agents are not allowed to sign for any applicant and should never sign forms on behalf of
clients to accommodate their needs. This practice is not permitted.
Signatures are to be written and must be legible.
Spouses are not allowed to sign for each other.
All applicants age 16 and over (18 and over in Missouri) are required to sign the
application. Parents or guardians may only sign for minor children.
Stamped signatures are not acceptable.
Required Signatures
The key applicant must sign at the bottom of page 2.
Spouses must sign at the bottom of page 2 if they are also seeking coverage under this
policy.
Dependents 16 years and older (18 in MO) must sign at the bottom of page 2 if they are
also seeking coverage under this policy. A parent or guardian can sign for children under
age 16 (18 in MO).
The key applicant must sign the Authorization to Obtain Protected Health Information.
Spouses must sign the Authorization to Obtain Protected Health Information if they are
also seeking coverage under this policy.
Dependents 16 years and older (18 in MO) must sign the Authorization to Obtain
Protected Health Information if they are also seeking coverage under this policy. A parent
or guardian can sign for children under age 16 (18 in MO).
Mail the application to the Home Office as soon as possible. Applications including list bills
must be received at the Home Office within 30 days of the application date.
Authorization to Obtain PHI
As a result of HIPAA privacy regulations, providers of health care are requiring an
authorization signed by the individual patient before medical information can be released.
The authorization on page eight is designed to meet all of the provider’s requirements for
release of plan of health insurance (PHI). For any medical condition listed on the application,
it is necessary that each individual applicant complete the authorization.
The key applicant, spouse, and any dependents over the age of 16 (18 in MO) who have
listed any medical conditions must complete the authorization. This requires that the
provider’s (physician, chiropractor, facility, etc) name, address, and phone number be given
at the top of the page.
Each individual must then sign the authorization at the bottom of the page. A parent or
guardian can sign for children under age 16 (18 in MO). The authorization must be dated to
Rev. April 2005
American Community Mutual Insurance Company
Writing Reinstatement Applications
5-7
be valid. To assist the provider in identifying the correct patient, the social security number
and date of birth is required.
After signing the authorization, the agent must detach the yellow copy and give it to the
applicants. This is required by law.
HIPAA privacy regulations also outline the applicant’s rights regarding Protected Health
Information, and required that each applicant be given a copy of these rights. To assist the
agent in fulfilling this responsibility, a complete Notice of Privacy Rights is contained on the
back of the yellow copy of the authorization. Even if the applicant did not have to complete
the authorization, the yellow copy must be detached and given to the applicant.
American Community Mutual Insurance Company
Rev. April 2005
5-8
Writing Reinstatement Applications
Rev. April 2005
American Community Mutual Insurance Company
6 Dependents and
Existing
Policies/Certificates
Adding Dependents to an Existing
Policy/Certificate
New applications to add dependents to policies/certificates require full underwriting except
for newborns (and children placed for adoption in certain states). A new fully completed
application for the dependent is required to add a dependent for coverage.
Only the spouse and any unmarried children who are at least 15 days old and have not yet
reached their 22nd birthday can be included on the application.
Children, stepchildren, and legally adopted children who are legally dependent on the
applicant are eligible for coverage.
Divorced spouses are not eligible under the key applicant. They must submit a separate
application.
Grandchildren who are in the legal custody of their grandparents can be added to a
grandparents’ policy/certificate/certificate if they are legally dependent on their
grandparents. Grandchildren are subject to underwriting. The grandparents must provide
copies of their guardianship papers.
Additional children can be added to a child-only policy/certificate. The child must be at
least 15-days old and less than 18-years old to apply.
Coverage for Newborns
Coverage of newborn children is automatic and continues for 31 days, provided at least
one adult family member is insured on the existing policy/certificate.
Payment of any required premiums must be made to the Home Office within 45 days of
the birth or adoption, and written notice of the birth should be sent to the Home Office
within 31 days of the birth to continue coverage beyond the automatic 31-day period.
If no additional premium is required for the dependent child, coverage is continued but
written notice of the birth to the Home Office is needed.
American Community Mutual Insurance Company
Rev. April 2005
6-2
Dependents and Existing Policies/Certificates
Dependents may only be added to a permanent policy/certificate. Dependents may not be
added to a short-term policy/certificate.
Coverage of Adopted Children
Coverage of adopted children is automatic and continues for 31 days, provided at least
one adult family member is insured on the existing policy/certificate.
Payment of any required premiums must be made to the Home Office within 45 days of
the adoption, and written notice of the adoption should be sent to the Home Office within
31 days of the adoption to continue coverage beyond the automatic 31-day period.
In Michigan an application must be completed to add an adopted child to an existing
policy; the application can be fully underwritten.
Removing Dependents From an
Existing Policy/certificate
The request to remove a dependent from an existing policy/certificate must be made in
writing from the key insured. The removal of dependent will be effective the due date
following the date the request is received in the Home Office.
Rev. April 2005
American Community Mutual Insurance Company
7 Risk Selection
The following information outlines the sources that underwriters use to assist in making a
risk determination. Lists of common medical conditions, occupations, and avocations with
their associated underwriting actions are also supplied. Some medical conditions, hazardous
occupations, or avocations (hobbies) might require an exclusion rider or a premium rating at
the time of issue.
Some exclusion riders can be removed after a period of time. The rider will state when the
exclusion can be reviewed for removal. Applicants and agents must initiate the process to
have exclusion riders reviewed in the states of Arizona, Illinois, Iowa, Missouri, Nebraska,
and Ohio. Upon receipt of the request, Medical Underwriting will review the case
completely. Medical records or a paramedical examination might be required. An exclusion
rider might be continued after it has been reviewed. The applicant and the agent will be
notified of the underwriting determination.
Riders issued in Michigan will have the rider automatically removed at the time specified in
the rider. The maximum medical rider exclusionary period in Michigan is 12 months.
NOTE:
ACMIC does not issue exclusionary riders in Indiana.
Medical Records
Medical records are the most effective source of information for risk selection. The ordering
of medical records is at the discretion of the underwriter. Medical records are usually
requested when medical conditions admitted on the application need further clarification, to
assess the risk of future health claims, or to gain a clearer picture of the applicant’s health
status.
Applicants must completely record all of their prior health history on the application.
American Community Mutual Insurance Company (ACMIC) does not order medical records
on every application. In cases where medical record review is indicated, ACMIC will request
complete copies of all medical records and special studies. A letter from the physician will
not be accepted in lieu of actual medical records.
The submission of a prescreen form can eliminate completing a permanent application for a
client with medical conditions that might result in automatic declinations.
American Community Mutual Insurance Company
Rev. April 2005
7-2
Risk Selection
Medical records are ordered from the provider by ACMIC and sent directly to the Home
Office. If the provider is unwilling to release records, the applicant will be notified that
assistance in obtaining the records is needed. If the provider will not release the records
within 30 days of the request, the case is closed and the agent is notified.
Agents can view the request for records, all follow-up communications and the date the
records are received on the ACMIC Web site.
An applicant may request a copy of all medical records in ACMIC’s possession by
submitting a written request. ACMIC will not release complete medical records to an agent
unless the applicants submits a written authorization.
Paramedical Examinations
Applicants with no admitted medical history or family physician listed on the application
might be subject to a paramedical examination. Paramedical examinations consist of medical
information, height, weight, blood pressure, blood profile, and urine specimen.
When an underwriter determines that a paramedical examination is needed, the request is
sent directly to the ACMIC contracted vendor. This ensures cost, quality control and
confidentiality, as required under federal and state privacy laws and regulations. Because
this is an exclusive contract, the agent is not allowed to order the paramedical examination.
Results of the paramedical examination and all blood work are sent directly to ACMIC.
Applicants may request a copy of the exam and the lab results by submitting a written
request. ACMIC will not release the actual results of the examination or lab work to the
agent unless the applicant submits a written authorization.
Procedures Regarding HIV Consent Forms
The agent is not required to provide an HIV Consent Form to the client. To ensure that the
applicant is fully aware of their rights, ACMIC will mail a state-approved HIV Consent Form
(in Michigan this includes the mandated HIV Booklet) to each applicant. A postage-paid
envelope will be included to facilitate return of the form. At the time the blood is drawn, the
examiner will give the applicant another approved form/booklet and obtain a signed HIV
Consent Form.
Blood and Urine Analysis
While it is beyond the scope of this manual to provide a detailed review of blood/urine
analysis, the more common causes of abnormal test findings are mentioned.
Rev. April 2005
American Community Mutual Insurance Company
Risk Selection
7-3
Underwriters can order blood and urine tests as needed to assess the risk. Normally, the
blood and urine tests performed include:
Alkaline Phosphatase
Alkaline phosphatase is an enzyme released into the bloodstream from the bones and liver.
Therefore, elevated levels may be provoked by a variety of disorders affecting the skeleton
and/or the liver and bile ducts.
Bilirubin
Bilirubin is a byproduct of the breakdown of old red blood cells. Bilirubin may be reported
on a blood profile as indirect, direct, or total. When indirect bilirubin is elevated, it is often
because of a benign impairment known as Gilbert’s Disease. Elevated levels of direct
bilirubin are more significant since they may indicate chronic liver disease.
BUN (Blood Urea Nitrogen)
BUN is a byproduct of protein metabolism. The waste substance, urea, is excreted by the
kidneys. If kidney function is significantly impaired, the BUN levels in the bloodstream will
rise. Non-pathological causes, such as dehydration, may also elevate BUN levels.
Cholesterol
Cholesterol is a type of blood fat, which has been found to contribute to coronary artery
disease. While heredity might play a role in elevated cholesterol levels, the majority of
elevated levels of cholesterol are caused by life habits such as dietary intake and physical
activity. In addition to assaying the cholesterol level, HDL (high-density lipoprotein) levels
are helpful in determining the risk of coronary artery disease. HDL is thought to remove
excess cholesterol from the walls of the blood vessels, thereby inhibiting the formation of
atherosclerotic plaques.
Creatinine
Creatinine is a byproduct of muscle metabolism. Like BUN, it is also cleared by the kidneys.
Elevated blood creatinine levels may be associated with impairment of kidney function.
GGT (Gamma-Glutamyl Transpedtidase)
GGT is an enzyme, which is used to screen for liver disease and/or prolonged, excessive
alcohol ingestion. Persons with an elevated GGT have an increased risk for either or both of
these impairments. The risk associated with an elevated GGT is dependent on multiple
factors: degree of elevation, other liver enzymes elevations, and medical history.
Glucose
Glucose is blood sugar. Fasting blood sugar (FBS) is used to evaluate insurance applicants
who may be at increased risk for having diabetes mellitus. Ideally, fasting blood sugar
measurement should be done after an overnight fast.
American Community Mutual Insurance Company
Rev. April 2005
7-4
Risk Selection
LDH (Lactic Dehydrogenase)
LDH is an enzyme found in many cells and tissues. Elevated blood levels may be due to a
wide variety of impairments.
SGOT (AST) and SGPT (ALT)
These enzymes are used to screen for liver disease. Persons who have an elevated AST
and/or ALT have an increased risk for liver disease. The risk associated with an elevated
AST or ALT is dependent on multiple factors: degree of elevation, other liver enzyme
elevations, and medical history.
Triglycerides
A type of fat, which has been linked to, increased risk of coronary artery disease and liver
disease. Whenever possible, fasting triglyceride values should be obtained. Non-fasting
results may be distorted by recent carbohydrate intake. In most cases, additional studies
including fasting blood sugar, cholesterol, HDL and GGT are also requested whenever
triglyceride levels are rechecked. This is because elevated triglycerides are also associated
with diabetes and liver disease.
HIV Blood Test
NOTE:
A state HIV Consent Form is required from the applicant prior to testing.
When drawn, blood will be tested for the antibodies to the virus, which causes AIDS. A
three-stage testing procedure is used which is very sensitive and specific. A positive test does
not mean that a person has AIDS but rather that they have been exposed to the virus that
causes AIDS. All applicants with positive tests will be declined. The results will be kept
strictly confidential.
Nicotine Testing of Urine Specimens
All urine specimens received for any reason are tested for cotinine, a substance found in the
urine of tobacco users. Applicants who deny using any form of tobacco and whose nicotine
test is positive for cotinine will be considered to be tobacco smokers for risk classification
purposes.
Occasionally, applicants will express to agents concern that second hand smoke will affect
the nicotine levels found in the urine. While medical research has shown the negative effects
of second hand smoke, ACMIC has set the nicotine level high enough to eliminate false
positive results. However, if the second-hand exposure to nicotine is so intense as to meet
smoker levels, the individual can be rated or declined due to the additional risk. For example,
a severe asthmatic with a high cotinine level due to second hand smoke.
Rev. April 2005
American Community Mutual Insurance Company
Risk Selection
7-5
Additional Data Sources
To accurately assess the underwriting risk, underwriters can access data sources such as
medical databases, pharmacy data, Department of Motor Vehicles, etc.
Pharmacy data allows access to prescription information for a five-year period of time. This
data provides the name of the medication, use, dose, refills, and all information regarding the
provider ordering the medication.
Medical Questionnaires
The agent can initiate a medical or non-medical questionnaire, thereby saving time in the
underwriting process. If the applicant or any dependents have answered yes to any of the
pertinent questions on pages 4 and/or 5 of the application, there may be an associated
questionnaire.
Questionnaires are intended to obtain more detailed information from the applicant about a
specific health condition, such as allergies or asthma, a potentially hazardous occupation or
avocation, or foreign residence or travel. Often, when the completed questionnaire is
submitted with the application, the Underwriter may find the information sufficient and
ordering medical records becomes unnecessary. See a complete list of medical questionnaires
in appendix B.
Medical Risk Selection Criteria
General Information
Applicants age 17 and older who are not replacing existing insurance, and applicants ages
50 and older, are required to take a current paramedical exam to include blood profile
(with HIV) and urinalysis if they have not consulted an attending physician in the
previous one-year. The underwriter will determine if medical records older than one year
can be obtained in lieu of the paramedical examination.
Paramedical exams may also be required to accurately gauge weight for rating, assess the
status of an on-going medical condition or obtain blood/urine specimens.
The medical records might be requested for any applicant who has consulted an attending
physician within three years of the date of application for a medical condition.
An underwriter will order the required paramedical examinations.
Agents are not allowed to order paramedical examinations.
American Community Mutual Insurance Company
Rev. April 2005
7-6
Risk Selection
ACMIC reserves the right to request additional information for consideration in
underwriting at any time during the risk selection process.
To Change Tobacco Use to Non-Tobacco Use Status
The insured must request a reconsideration of smoker rating. ACMIC requires 12 (12)
months of non-tobacco use and a current application. ACMIC will request a urine specimen
for testing before considering a change from tobacco use to non-tobacco use status.
Short-term Field Underwriting
Individuals who have health conditions or non-medical risk which would cause them to be
declined for renewable health insurance should not be submitted for short-term coverage.
Substandard Risk
Applicants who present a risk greater than the general population will be assessed an
additional premium rating. If the risk cannot be sufficiently addressed by a rating or a rider,
the case will be declined.
Percentages of premium increase are:
Table One
25% extra premium
Table Two
50% extra premium
Table Three
75% extra premium
Table Four
100% extra premium
Multiply the individual’s base policy/certificate premium by the rate-up percentage to
determine the Substandard Class premium charge.
Substandard Class ratings apply to the premium of the applicant with the medical
condition and not to other family members.
NOTE: Substandard ratings do not attach to options such as dental or maternity.
The maximum substandard extra premium is 100% (Table Four). Risk beyond Table
Four is declined.
NOTE:
HIPAA applicants cannot be declined or rated differently than any other
applicant. Therefore, the underwriter will assess the risk that the applicant
presents and, if appropriate, will attach a table rating from Table 1 to a
maximum of Table 16 for applicants from Arizona or Missouri. Table 16 is
assigned to a HIPAA risk that would normally be a decline.
Health Insurance Build Charts (Adult and Juvenile)
The build charts are designed to assist agents in the field underwriting of individuals who
might be overweight or underweight. The height and weight charts assume no other medical
impairments.
Rev. April 2005
American Community Mutual Insurance Company
Risk Selection
7-7
A combination of multiple medical conditions (co-morbidity) such as overweight and
hypertension might mean that the risk selection decision will be more severe than the build
chart or the individual rating indicates. Agents should call the Medical Underwriting
Department for questions about multiple medical impairments in conjunction with build
problems.
If there has been any weight loss in the past 12 months, add half of the weight loss to the
current weight for risk classification purposes. A full 12 months at the lower weight is
required to receive full credit for the entire weight loss.
Adult applicants who have build measurements outside the range of the charts will not be
considered for health insurance.
American Community Mutual Insurance Company
Rev. April 2005
Health Insurance Build Chart
Males and Females Ages 15 and Over (Revised 7/97)
Height
Underweight
Special Class
Rate Up by 25%
Female
4’08”
4’09”
4’10”
4’11”
5’00”
5’01”
5’02”
5’03”
5’04”
5’05”
5’06”
5’07”
5’08”
5’09”
5’10”
5’11”
6’00”
6’01”
6’02”
6’03”
6’04”
6’05”
6’06”
6’07”
6’08”
75
77
79
81
83
85
87
90
92
94
96
99
102
105
107
111
115
118
120
123
127
—
—
—
—
Male
—
—
—
—
90
93
97
100
103
106
109
112
116
119
122
125
129
133
137
141
144
148
152
156
160
25%
Table 1
Female
Overweight
Special Class
Rate Up Percent
50%
75%
100%
Table 2
Table 3
Table 4
156
161
165
168
172
177
181
187
191
196
200
206
212
219
223
232
239
245
251
257
264
—
—
—
—
167
172
176
179
184
189
193
200
204
209
214
220
226
234
239
248
256
262
268
275
282
—
—
—
—
Average Weight
Female
107
110
113
115
118
121
124
128
131
134
137
141
145
150
153
159
164
168
172
176
181
—
—
—
—
Male
—
—
—
—
129
133
138
143
147
151
156
160
165
170
174
179
184
190
195
201
206
211
217
223
228
177
182
186
190
195
200
205
211
216
221
226
233
239
248
252
262
271
277
284
290
299
—
—
—
—
185
190
195
199
204
209
215
221
227
232
237
244
251
260
265
275
284
291
298
304
313
—
—
—
—
Male
Overweight
Special Class
Height
Rate Up Percent
Decline
(Risk
Unacceptable
192
197
202
206
211
217
222
229
234
240
245
252
260
269
274
285
294
301
308
315
324
—
—
—
—
25%
Table 1
50%
Table 2
75%
Table 3
100%
Table 4
—
—
—
—
175
181
188
194
200
205
212
218
224
231
237
243
250
258
265
273
280
287
295
303
310
—
—
—
—
187
193
200
207
213
219
226
232
239
247
252
260
267
276
283
291
299
306
315
323
331
—
—
—
—
199
205
213
220
226
233
240
246
254
262
268
276
283
293
300
310
317
325
334
343
351
—
—
—
—
209
215
224
232
238
245
253
259
267
275
282
290
298
308
316
326
334
342
352
361
369
Decline
(Risk
Unacceptable
—
—
—
—
218
225
233
242
248
255
264
270
279
287
294
303
311
321
330
340
348
357
367
377
385
NOTE: Any weight loss in the past 12 months - add ½ of the weight loss to the current weight for risk classification purposes.
The Medical Underwriting Department will require a Paramedics Examination, Blood Profile, and Urinalysis for any Applicant who is a possible Rated Case due to build.
4’08”
4’09”
4’10”
4’11”
5’00”
5’01”
5’02”
5’03”
5’04”
5’05”
5’06”
5’07”
5’08”
5’09”
5’10”
5’11”
6’00”
6’01”
6’02”
6’03”
6’04”
6’05”
6’06”
6’07”
6’08”
Juvenile Build Chart
Height
24”
26”
28”
30”
32”
34”
36”
38”
40”
Ages 0-2
Minimum
8
10
13
15
18
21
23
26
29
Maximum
23
26
31
36
40
42
45
48
52
Height
30”
34”
38”
42”
46”
50”
54”
58”
Ages 3-9
Minimum
18
22
26
32
38
46
56
66
Maximum
40
44
54
64
78
94
111
128
Height
48”
52”
56”
60”
64”
68”
72”
76”
Ages 10-14
Minimum
44
54
63
74
87
100
113
126
Maximum
92
108
126
144
166
186
206
228
Juveniles outside printed range will be considered on an individual basis: Contact Medical Underwriting Department.
American Community Mutual Insurance Company
Rev. April 2005
Risk Selection
7-9
7-10
Risk Selection
Unacceptable Medical and Non-medical Conditions
Please call the Medical Underwriting Department if you encounter a questionable risk that is
not listed here.
Addison's Disease
Adrenal Gland Disorders
AIDS or ARC
Alcohol Abuse or Treatment
within past 8 years
(within 5 years if in AA)
ALS
Alzheimer’s Disease
Aneurysm
Angina Pectoris
Anxiety Disorder, Severe
Aplastic Anemia
Arteriosclerotic Heart
Disease
Artificial Pacemaker
Asthma, Severe
Atrial Fibrillation or Flutter
(within past 5 years)
Autism (Individual
Consideration based on
State laws)
Autoimmune Diseases
Blood dyscrasias
Brain Tumor
Bright’s Disease
Cancer - Call Underwriting
- (can consider basal cell
skin cancer after
removal)
Cardiomyopathy
Cerebral Palsy
Cerebral Vascular Accident
Chronic Fatigue (unless
treatment free for 10
years)
Cirrhosis of Liver
Cocaine Use
Rev. April 2005
Colitis, Ulcerative
(recurrent in past 5
years)
Collagen Diseases
Confined to Nursing Home
or Hospital
Congestive Heart Failure
Connective Tissue Diseases,
Lupus (LE)
COPD-Chronic Obstructive
Pulmonary Disease
Coronary Artery Disease
Craniotomy 5 years (due to
trauma and no residuals)
Crohn’s Disease-Regional
Enteritis (within past 4
years)
Cystic Fibrosis
Dementia
Depression, Severe, Chronic
Diabetes
Driving while driver’s
license suspended
within past year
Drug Treatment &
Rehabilitation
(reconsider after 8
years)
Drug Use (selling or
dealing)
Dwarfism, Gigantism
DWI, DUIL, within past
year
DWI, DUIL, two or more
episodes (decline until 5
years from date of last
offense)
Eating Disorders, Bulimia,
Anorexia Nervosa, Pica
(within past 7 years)
Emphysema
Encephalitis (other than
post-infectious within
past 3 years)
Endocarditis
Enlarged Heart
Epilepsy (Seizure within
past 2-5 years)
Esophageal Varices
Gastrectomy
Gastric bypass/stapling/
banding
Glomerulonephritis (within
past 2 years)
Gullian-Barre Syndrome
(within past year)
Heart Attack-Coronary
InsufficiencyMyocardial Infarction
Heart Murmurs, Organic
Heart Surgery, except Septal
Defect
Hemophilia (or other
bleeding disorders)
Hemiplegia-Hemiparesis
Henoch-Schonlein Pupura
(within past 5 years)
Hepatitis B (within past
year)
Hepatitis C
Hepatitis - chronic
American Community Mutual Insurance Company
Risk Selection
High Blood Pressure
(uncontrolled or newly
diagnosed products)
HIV Infection
Hodgkin’s Disease
Hydrocephalus
Hydronephrosis (within past
year)
Kidney Cysts (Bilateral)
Kidney Failure or Dialysis
Kidney Stones ( Present)
Kidney Transplant
Recipient
Leukemia
Liver Abscess (within past
year)
Liver Transplant Recipient
Lymphedema
Lupus Erythematosus (LE)
Manic Depressive
Marfan Syndrome
Marijuana Use
Medullary Sponge Kidney
(Bilateral)
Meniere’s Disease (within 5
years)
Mental Retardation (severe,
emotionally unstable or
with psychiatric
conditions or under 18)
Mitral Valve Disease
Multiple Sclerosis
Muscular Dystrophy
Myasthenia Gravis
Narcolepsy, Cataplexy
Nephrectomy (due to
disease)
Organ Transplant Recipient
Obesity Surgery
Osteogenesis ImperfectaBone Disease
Pacemaker, Artificial
Paget’s Disease of Bone
Palsy or Paralysis
Pancreatitis (within past 3
years)
Paraplegia
Parkinson’s Disease
Pericarditis (within past 2
years)
Periarteritis Nodosa
Peripheral Vascular Disease
(except Raynaud’s)
Pernicious Anemia
Phlebitis (multiple episodes
within past 5 years)
Pituitary Gland Disorders
Pneumothorax (3 or more
episodes, unoperated,
within past year)
Polio
Polycystic Kidney Disease
Pregnancy (applicant,
dependent, or significant
other whether or not
listed on application)
Psychiatric/Psychological
Disorders, Severe
Pulmonary Fibrosis
Pulmonary Embolism
(within past 6 months)
Pulmonary Hypertension
Pyelonephritis (Chronic or
more than 2 episodes)
Quadriplegia
Renal Failure
Reye’s Syndrome (within
past 6 months)
Rheumatoid Arthritis
Rickets
Sarcoidosis-Pulmonary
(within past 2 years)
Schizophrenia-Paranoia
Scleroderma
Sleep Apnea
Sickle Cell Anemia
American Community Mutual Insurance Company
7-11
Spinal Deformity, Severe
Stroke (Cerebral
Hemorrhage,
Thrombosis or
Embolism)
Suicide Attempt (within
past 10 years)
Syndrome X
Thrombosis
TIA (Transient Ischemic
Attack)
Thrombocytopenia
Toxic Shock Syndrome
(within past 6 months)
Transplants
Undiagnosed Conditions
Ventricular Arrythmias
Von Recklinghausen’s
Disease
Von Willebrand’s Disease
Weight-OVER or UNDER
(See Build Chart)
Rev. April 2005
Medical Risk Guide
For agent convenience, the following is a list of the most common medical conditions and the probable underwriting action. Since
each person’s medical condition is unique to the total health status of the individual, this is a guide only. It is intended to provide
general field underwriting direction. Final decisions depend on individual case circumstances and will be made by a Home Office
underwriter. In some instances that underwriter can offer options such as a rider or a rating. These optional offers are at the
underwriter’s discretion. In states that allow exclusionary riders, applicants requiring more than three exclusion riders will not be
accepted for coverage. Applicants who are declined for insurance will be notified of available state risk pools or open enrollments as
appropriate.
Symbols
RFC = Rate for Cause
Std = Not Rated
Rider = Exclusion Rider
IC = Individual Consideration. Can be a rider, rating or decline
PP = Postponed for current underwriting until a future time
Impairment
Acne
Alcohol Related Offenses (including
DWI)
1 within past year
Multiple events for 5 years from date
of last event
Alcoholism History
Action
Rider in AZ IL MO NE
OH; rate in MI and IN
Considerations
Note: many individual policies do not provide coverage for
acne. In those cases no rating or rider is applied.
Decline
Decline
Decline
Consider if 8 years without alcohol or 5 years if in AA or
therapy
Allergies/Hay Fever (Seasonal Only)
Prescription medications or injections
within past 2 years
Anemia
Iron Deficiency (Females)
All Others
Anxiety and Depression - Situational
Episodes
Mild
Moderate
Severe
Required hospitalization within 5
years
After 5 years
Arthritis
Osteoarthritis
Asthma
Non-smokers with no medical
treatment in past 2 years
Non-smokers with treated asthma in
the past 2 years
Severe cases or smoker - all ages
Standard
Rate or riders in AZ IL
MO NE OH; rate in MI
and IN
Usually standard
IC
Standard
IC to Decline
Seasonal only, over the counter medications, no medical
consultations
Offer dual option when possible.
Based on cause, lab work, treatment and symptoms
One episode of Situational depression within past 2 years
lasting less than six months. Not on any medication
Anxiety with recovery over one year and treatment that
lasted less than one year with no hospitalization
Decline
Decline
IC
IC
Based on joint involvement and medication
Standard
Rate or rider in AZ IL
MO NE OH; rate in MI
and IN
Decline
American Community Mutual Insurance Company
Offer dual option when possible.
Frequent attacks, multiple hospitalizations or medications in
excess of rating
Rev. April 2005
Risk Selection
7-13
Back and Spine Disorders
Sprain or Strain
Acute, recovered
Chronic
Curvature of Spine (Scoliosis)
Mild (Age 21 and up)
Moderate or child
Severe
Operated with rod
Fractures
Sciatica
Acute, recovery over 2 years
Recurrent
Ruptured Disc/Degenerative Disc
Disease
Unoperated
Operated
Standard
Rider in AZ IL MO NE
OH; rider/rate in MI; IC
in IN
Last treatment six months prior to application date
Standard
Rider in AZ IL MO NE
OH; rate/decline in MI
and IN
Decline
Rider in AZ, IL, MO,
NE, OH for 5 years; rate
in IN, MI
Rider in AZ IL MO NE
OH; IC to decline in MI
and IN
No change in x-rays
Based on x-rays, treatment
Standard
Rider in AZ, IL, MO,
NE, OH; rate in IN, MI
If less than 2 years since recovery — Rider
Rider in AZ IL MO NE
OH; decline in MI and
IN
Rider in AZ IL MO NE
OH; rate in MI and IN
Fracture healed, treatment completed
Standard after 6 months with no complications
Current Chiropractic Treatment
Spina Bifida
Unoperated
Operated
Bell’s Palsy
Present
Recovered
Residuals
Breast Conditions
Augmentation or Implants
Cyst
Single occurrence, benign and excised
Others
Fibrocystic Breast Disease
Symptomatic
Non-Symptomatic
IC based on cause
Decline
IC
PP
Standard
Rider in AZ IL MO NE
OH; rate or rider in MI;
rate in IN
Based on age, nerve conduction, and time since surgery
No residuals
Rider in AZ IL MO NE
OH; rate in MI and IN
Standard
IC
IC
Rider in AZ IL MO NE
OH; rate or rider in MI;
rate in IN
Standard
American Community Mutual Insurance Company
Based on state mandates
More than one biopsy regardless of diagnosis is a decline in
MI and IN
More than one biopsy regardless of diagnosis is a decline in
MI and IN
Rev. April 2005
Risk Selection
7-15
Bronchitis
Present
Acute, Recovered — non-recurring
Recurrent — Mild to moderate, nonsmoker
Chronic or Smoker
Caesarean Section — within past 10
years; applicants through age 45
Carpal Tunnel Syndrome
Unoperated
Operated
Cholesterol Elevated
Chronic Fatigue Syndrome
Cleft Palate/Cleft Lip
Present (or surgery with residuals)
Surgery - complete recovery, no
further operations planned, no
residuals
PP
Standard
Rider in AZ IL MO NE
OH; rate in MI and IN
Decline
Rider in AZ IL MO NE
OH; rate in MI and IN
Rider in AZ IL MO NE
OH; decline in MI and
IN
Rider in AZ IL MO NE
OH; rate in MI and IN
Rating or decline
Decline
Rider in AZ IL MO NE
OH; decline in MI and
IN
Standard
One episode
No rating/rider if normal vaginal delivery since C-Section,
or partner has had a vasectomy, or Applicant is postmenopausal or has had a hysterectomy or tubal ligation
Three years since surgery
Rate for treatment to maximum decline
Colitis
Spastic Colon, Irritable Bowel
Syndrome (mild)
Ulcerative Colitis/Crohn’s
Disease/Regional Enteritis
Present
After 10 years with surgical
treatment
Without surgery
Deafness
Deviated Nasal Septum
Present
Operated
Diverticulitis (complete recovery)
Single episode
Multiple episodes
Operated
Colostomy present
Driving Record (Adverse)
Rider in AZ IL MO NE
OH; rate in MI and IN
IC for Moderate to Severe treated with medications
Decline
Rider in AZ IL MO NE
OH; IC in MI and IN
Decline
IC based on cause
Rider in AZ IL MO NE
OH; IC in MI and IN
Standard
Rider in AZ IL MO NE
OH; IC by MD in MI
and IN
Rider in AZ IL MO NE
OH; decline in MI and
IN
Rider in AZ IL MO NE
OH; rate in MI and IN
Decline
IC
American Community Mutual Insurance Company
Decline multiple or chronic episodes within one year
In MI and IN, for greater than 1 year since last episode, IC
by MD
Rev. April 2005
Risk Selection
7-17
Drug Usage
Other than marijuana within past 8
years use or treatment
Marijuana Present use or use within
the past 2 years
After time period
Ear Disorders
Hearing Impairment
Adult
Children (Deafness)
Labyrinthitis
Present
Recovered, single, acute episode
Others
Meniere’s Disease/Syndrome Present
Recovery-within 5 years
After 5 years and recovered
Otitis Media
3 or more episodes per year
Decline
Decline
IC
Rider in AZ IL MO NE
OH; rate in MI and IN
Rider in AZ IL MO NE
OH; rate or decline in
MI and IN
Permanent rider and rating
Permanent rider and rating
PP
Standard
IC
Decline
Decline
Standard
Rider in AZ IL MO NE
OH; IC to Decline in MI
and IN
Punctured or Perforated Ear Drums
Traumatic
Standard
Others
IC
Complete recovery, trauma over one year prior to
application date
Esophagitis/Esophageal Reflux
Cause known
Cause unknown - occasional, mild
attacks
Chronic
Fibromyalgia
Fissure (Anal)
Unoperated
Operated, complete recovery
Fracture recent (other than knee, skull or
spine)
With internal fixation, 0-5 years
With no internal fixation over 1 year
Gallbladder
Gallbladder removed
Inflammation
Gall Stones Present
Rider in AZ IL MO NE
OH; rate to Decline in
MI and IN
Rider in AZ IL MO NE
OH; rate to decline in
MI and IN
Rider in AZ IL MO NE
OH; rate to decline in
MI and IN
Decline
Rider in AZ IL MO NE
OH; decline in MI and
IN
Standard
Rider
Rider in AZ IL MO NE
OH; rate in MI and IN
Standard
Decline Barretts
Recent fracture, less than one year from treatment, no
internal fixation
Rider or Rating for 5 years
No residuals
Standard
Rider in AZ IL MO NE
OH
IC by MD in MI and IN
Rider in AZ IL MO NE
OH
Decline in MI and IN
American Community Mutual Insurance Company
Rev. April 2005
Risk Selection
7-19
Ganglion Cyst - present
Gastritis/Gastroenteritis
Moderate
Severe or chronic
Gastric Bypass
Gynecological Disorders
Cervicitis
Mild acute attack (complete
recovery 1 year)
Chronic or prolonged attacks
Dilation and Curettage (D and C)
Following spontaneous abortion
(complete recovery 1 year)
With abnormal bleeding
Endometriosis Present
Post menopausal
Post total hysterectomy
Fibroid Uterus
Present
Rider in AZ IL MO NE
OH; IC in MI and IN
Operated with complete recovery is standard
Rider in AZ IL MO NE
OH; rate to Decline in
MI and IN
Rider in AZ IL MO NE
OH; decline in MI and
IN
Decline
Infrequent attacks, limited use of medications, results of
diagnostic work-up
Standard
Rider in AZ IL MO NE
OH; rate/Decline in MI
and IN
Standard
PP
Rider in AZ IL MO NE
OH; decline in MI and
IN
IC
Standard
Consider after symptoms have ceased
Rider in AZ IL MO NE
OH; IC Decline in MI
and IN
Rider Indefinitely
Operated (complete recovery)
Hysterectomy - for benign causes
Menstrual Disorders
Present
Recovered
Menopause - completely
asymptomatic
Ovarian Cyst
Present
Recovered or removed
Polycystic Ovarian Disease
PAP Smear
Abnormal
After two normal PAP smears and
return to annual exam
Pelvic Inflammatory Disease
Current
Acute - recovered within 1 year
Acute - recovered over 1 year
Standard
Standard
After release from care
Rider in AZ IL MO NE
OH; rate/decline in MI
and IN
Standard
Standard
Rider in AZ IL MO NE
OH; rate/Decline in MI
and IN
Standard
Rider in AZ IL MO NE
OH; decline in MI and
IN
Rider Indefinitely
IC to Decline in MI and
IN; rider in AZ, IL, MO,
NE, OH
Standard
PP
Rider in AZ IL MO NE
OH; rate in MI and IN
Standard
American Community Mutual Insurance Company
Rev. April 2005
Risk Selection
7-21
Chronic within 2 years
Pre-Menstrual Syndrome (PMS)
Moderate to Severe
Rectocele, Cystocele, Urethrocele
Present
Operated
Headaches/Migraines
Present and/or use medication and all
Migraines
Occasional without prescribed
medication or treatment
Hemorrhoids
Not surgically repaired
Surgically repaired
Hypertension/Blood Pressure
Hernia
Abdominal / Inguinal / Umbilical /
Ventral
Rider in AZ IL MO NE
OH; IC to decline MI
and IN
Rider in AZ IL MO NE
OH; decline in MI and
IN
Rider in AZ IL MO NE
OH; decline in MI and
IN
Standard
Indefinitely
Rider in AZ IL MO NE
OH; rate/decline in MI
and IN
Standard
Rate or rider dual offer in AZ, IL, MO, NE, OH
Rider in AZ IL MO NE
OH; IC to decline in MI
and IN
Standard
Table One
Minimum Rating
Require 1 year of controlled blood pressure if non-tobacco
user; require 2 years control of blood pressure if tobacco
user; APS required for all Applicants
Present
Operated (complete recovery)
Hiatal
Unoperated
Operated over 6 mos. Ago and
complete recovery
Hypoglycemia
Mild, asymptomatic, diet-controlled
Others
Kidney Disorders
Kidney Stones (Unilateral - Present)
Unilateral and passed stone
Kidney Stones (Bilateral - Present)
Kidney Stones - More than 2 episodes
(complete recovery)
Other
Multiple episodes of surgery
Lyme Disease
Present
Acute infection with recovery less
than 12 months
Rider in AZ IL MO NE
OH; IC to decline in MI
and IN
Standard
Rider in AZ IL MO NE
OH; IC to decline in MI
and IN.
Standard
Standard
IC
Rider in AZ IL MO NE
OH; decline in MI and
IN
Rider in AZ IL MO NE
OH; rate in MI and IN
Decline
Rider in AZ IL MO NE
OH; rate in MI and IN
Call Underwriting
Rider in AZ IL MO NE
OH; IC by MD in MI
and IN
Decline
Decline
American Community Mutual Insurance Company
Indefinitely
Rider 2 years from recovery, IVP clear
5 years from last attack, IVP clear
Indefinitely
Consider after 1 year completed treatment
Rev. April 2005
Risk Selection
7-23
All other types with complete
recovery less than 3 years
Osteoporosis
Osteopenia
Osteoporosis
Osteoporosis under age 50 or with
symptoms
Decline
Consider after 3 years completed treatment
Rate/decline
Lab studies required to distinguish between osteopenia and
osteoporosis
Consideration given to age, lab values, effective treatment
IC to Decline
Decline
Pancreatitis
0-3 years (single attack)
Multiple attacks
Alcohol Involvement
All Others
Pregnancy (Applicant, spouse or any
significant other whether on
application or not)
Prostate Disorders
Benign Prostate Hypertrophy Mild,
asymptomatic
Symptomatic with or without surgery
Prostatitis
Chronic history
Acute
Prostatectomy (Removal of prostate)
Benign Biopsy Report
Malignant
Rectal Disorders
Fissure
Single episode, operated, complete
recovery
Others, unoperated
Decline
Decline
Decline
IC
Decline
5 years from last attack/symptom
Consideration given to underlying cause
Standard
Rider in AZ IL MO NE
OH; rate/Decline in MI
and IN
Consideration given to type of surgery
Rider in AZ IL MO NE
OH; rate to Decline in
MI and IN
Standard
Completely recovered, no episodes in last two years.
One episode, mild, complete recovery, no further symptoms
Standard
Decline
10 years
Standard
IC of a Rider in AZ IL
MO NE OH
Decline in MI and IN
American Community Mutual Insurance Company
Rev. April 2005
Risk Selection
7-25
Fistula (Anorectal)
Single episode, operated, complete
recovery
Others, unoperated
Hemorrhoids
Not surgically repaired
Surgically repaired
Respiratory Disorders
Collapsed Lung (Pneumothorax)
COPD (Chronic Obstructive
Pulmonary Disease)
Pleurisy
Present
Single attack, recovered
Multiple episodes
Pneumonia
Present
Single attack, recovered
Multiple attacks
Pulmonary Embolism
Present or Multiple episodes
Single episode, recovered 1 year,
no medications
Continuing Rx (Anti-coagulants)
Tuberculosis
Present
Standard
IC of a Rider in AZ IL
MO NE OH; decline in
MI and IN
Indefinitely
Rider in AZ IL MO NE
OH; IC to decline in MI
and IN
Standard
IC
Decline
PP
Standard
IC
PP
Standard
IC
Decline
Standard
Decline
Decline
May require an rating for cause
Others
Sinusitis
Acute, Recovered
Chronic
Temporomandibular Joint Dysfunction
(TMJ)
Present
Surgery completed
Thyroid Disorders
Toxic, minimal hyperthyroidism,
recent
Goiter present with Hyperthyroidism
Severe hyperthyroidism symptoms
Hypothyroidism, controlled, adults
Hypothyroidism in children
IC
Standard
Rider in AZ IL MO NE
OH; rate in MI and IN
Rider in AZ IL MO NE
OH; decline in MI and
IN
IC
2 years
Note if treatment is excluded by policy contract
IC to MD; rate in MI or
IN; rider in AZ, IL, MO,
NE, OH
IC to MD
Decline
Standard
IC to Decline
American Community Mutual Insurance Company
Rev. April 2005
Risk Selection
7-27
Tonsillitis/Adenoiditis
Multiple episodes within 1 year
Over 1 year recovery
Chronic, 3-5 episodes per year
Ulcers (Duodenal, Gastric, Peptic)
Present
One episode in past two years, no
bleeding or surgery
Multiple episodes (or history of
bleeding)
Undiagnosed Conditions of any body
system
Rider in AZ IL MO NE
OH; decline in MI and
IN
Standard
Rider in AZ IL MO NE
OH; decline in MI and
IN
Rider in AZ IL MO NE
OH; PP in MI and IN
Rider in AZ IL MO NE
OH; rate in MI and IN
Rider in AZ IL MO NE
OH; decline in MI and
IN
PP
Consideration given to clinical findings, lab work, treatment
Decline of coverage until testing complete and fully
diagnosed. IC based on results.
Urinary Tract Disorders
Cystitis (Bladder Infections)
Single episode, recovered (after 6
months)
Multiple or Chronic
Urinary Stress or Urge Incontinence
Present
Operated/Recovered
Urethritis
Single episode, recovered (after 1
year)
Multiple or Chronic
Urethral Stricture
Present
Multiple episodes, corrected by
dilatations
Standard
Rider in AZ IL MO NE
OH; IC to Decline in MI
and IN
3 years
Rider in AZ IL MO NE
OH; rate to decline in
MI and IN
Standard
Consideration of degree of incontinence, frequency, and
treatment with medication, surgical recommendation
Standard
Rider in AZ IL MO NE
OH; rate to decline in
MI and IN
3 years
Rider in AZ IL MO NE
OH; decline in MI and
IN
Rider in AZ IL MO NE
OH; decline in MI and
IN
American Community Mutual Insurance Company
Rev. April 2005
Risk Selection
7-29
Varicose Veins
Present - mild, lower extremities only der in AZ IL MO NE OH
te in MI and IN
Treated by surgery, procedure, or
der in AZ IL MO NE OH
injection
to decline in MI and IN
Surgically corrected
der in AZ IL MO NE OH
to decline in MI and IN
Vertigo Cause Unknown
Cause Known over 1 year since
episode
5 years no treatment or complications
Medical Records are needed
2 years
Risk Selection
7-31
Non-Medical Risk Selection Criteria
Occupations
Coverage is not available to any members of the Armed Forces or their families.
Unemployed individuals who will return at some point to the workforce must apply for shortterm insurance. Unemployed persons who are permanently retired or full-time students may
apply for permanent coverage.
The following industries require a rate-up or declination due to occupational illness or injury:
Correctional institution employees
Crop dusters
Carnival and circus workers
Worker in demolition, explosive, chemical, asbestos, toxic materials
Drilling/exploration operations of oil natural gas performed offshore/mainland
Drivers hauling explosives, taxi drivers
Entertainment industry
Firefighters
Foundry workers
Government agencies
Liquor industry (bars and lounges)
Logging industry
Mining operation, including strip mining
Motion picture industry
Motorcycle, ATV or vehicle competitors
Police personnel (patrol)
Professional or semiprofessional athletes
Racers (any type), stunt drivers,
Professional divers, skin/scuba divers
Roofers in construction industry
Security personnel, detectives, and private investigators
Steel workers
This list is not complete. Underwriter will make all determinations regarding any hazardous
occupation not listed.
Avocations
The following avocations (hobbies) might require a rate-up or declination due to hazardous
activities that present more than a standard risk of injury.
American Community Mutual Insurance Company
Rev. April 2005
7-32
Risk Selection
ATV
Automobile, boat, motorcycle, etc. (All types, on and off road.) competition
Martial arts
Mountain and rock climbing
Skiing (professional or instructors)
Skin-scuba diving
Sky diving
Stunt performance
Vehicle racing
Submit Aviation/Avocation Supplemental Questionnaire to Application on anyone who
participates in hazardous avocations.
Aviation Activities
Generally experienced pilots (100 solo hours) can be accepted without an exclusion rider
if their activities are non-hazardous.
Student pilots and hazardous aviation activity will require an exclusion rider for injuries
sustained while operating or riding in any type of aircraft (except for paying passengers
on commercial flights).
Submit Aviation/Avocation Supplemental Questionnaire to Application for any Applicant
who participates in aviation activities.
Foreign Travel
Foreign travel by United States citizens including students is acceptable if the travel
period was less than three months per year prior to applying for coverage, and the travel
was to a safe area. Safety is determined by the underwriter.
o A foreign travel questionnaire is required.
o The applicant must have no future plans to leave the country.
United States citizens who were residing in foreign countries, missionary workers, and
Peace Corp workers must be back in the United States six months with no future plans to
leave the country.
United States students may not apply for coverage prior to leaving the country to travel
since this would constitute travel insurance.
Non-US Citizens
Canadian citizens temporarily residing in the United States cannot be accepted for health
insurance coverage if they have supplemental U.S. coverage on their Canadian insurance
policy/certificate.
Exchange students who have been in the United States less than one year can be accepted
for coverage if their medical record is favorable and they are traveling from residence in
Europe, Scandinavia, Australia, or New Zealand, and will remain in this country longer
than one year.
Rev. April 2005
American Community Mutual Insurance Company
Risk Selection
7-33
Requirements for foreign-born nationals:
o Foreign-born nationals must be United States citizens for at least one year before
applying (exception - Arizona applicants).
o Foreign-born nationals must be eligible to remain in the U.S. on a permanent basis
with no future plans to reside outside the U.S. (copy of Visa might be required).
o Medical records in English must be available for foreign nationals from Englishspeaking countries at the applicant’s expense.
o Foreign nationals from the following countries will be considered on an individual
basis after six months residence in the U.S.:
Australia
Canada
England
Ireland
Scotland
New Zealand
American Community Mutual Insurance Company
Rev. April 2005
8 After the Applicant Has
Signed
Sending the Application to ACMIC
Mail, fax, or e-mail the application to American Community Mutual Insurance Company
(ACMIC) as soon as possible after it is signed. Applications including list bills must be
received at ACMIC within 30 days of the applicant’s signature date.
Faxing the Application
Faxed applications will be accepted only if the initial method of two months’ premium
payment is by credit card (VISA or MasterCard) or electronic funds transfer (EFT).
If faxing, do not send the original application to ACMIC. The faxed application will be
considered the original application. Agents should keep the original application until they are
assured that the faxed copy has reached ACMIC and is of acceptable quality.
If Electronic Funds Transfer (EFT) is the requested method of payment after credit card
payment of the initial premium, the agent must fax the EFT authorization form and a voided
check with the application.
Faxed applications have the same priority as normal mail received the same date.
Status
The status of pending underwriting applications is available on ACMIC's Web site
(www.american-community.com) or from the National Sales Desk. The Call Center at the
Home Office can also provide phone status services.
Policy Delivery Procedures
Policies must be delivered promptly. The Ten Day Free Look provision for short-term and
permanent applications begins when the policy has been physically delivered to the
applicant.
American Community Mutual Insurance Company
Rev. April 2005
8-2
After the Applicant Has Signed
NOTE:
Policies without delivery requirements are sent directly to the applicant. Agents
will receive policies with delivery requirements.
Policies mailed directly to the agent provide the opportunity for careful review before
delivering it. If the policy contains an error, contact the Customer Service Center
immediately. If there is an error with the policy, the agent should not deliver it to the
applicant.
If the policy is rated, the agent must provide a new premium illustration. If the policy is
approved with an exclusion rider, the agent must review the rider terms and conditions with
the applicant(s) before they sign it. It is also necessary that the agent explain the Schedule of
Benefits page and the provisions of the policy.
Illinois law requires that an outline of coverage be delivered to the applicant with the
application. The applicant must acknowledge receipt of the outline of coverage. This is noted
on the application. If the insured decides to modify their requested coverage prior to the
delivery of the policy, the agent should present the applicant with a new outline of coverage.
Delivery of the policy provides an opportunity for the agent to confirm with the applicant
that there has been no change in the health or answers or statements of any of the applicants
prior to delivery of the policy. If the agent learns there has been such a change, the applicant
has an obligation to notify ACMIC in writing. Failure to do so might result in the policy
being rescinded.
Policy Delivery Requirements
Delivery requirements must be completed and returned to the Home Office in order to place
the insurance coverage in force after the policy has been approved conditionally and mailed
to the Agent for delivery.
Delivery requirements could be any of the following:
Amendment
Exclusion rider
State specific forms (i.e. Certification of Applicant)
Premium payment
Miscellaneous
Requests for policy benefits (claims) on losses that occur after the policy effective date will
not be processed until all policy delivery requirements are received at the Home Office.
Delivery requirements need to be returned to the Home Office within 30 days of the date the
policy is mailed to the Agent for delivery to the Applicant.
Rev. April 2005
American Community Mutual Insurance Company
After the Applicant Has Signed
NOTE:
8-3
The policy is not in force until all delivery requirements are completed.
ACMIC has a dedicated fax number in the Policy Issue Department for delivery
requirements. Agents should fax delivery requirements directly to the Policy Issue
Department.
Delivery Requirements and Not Taken Out (NTO) Policy Procedures
The applicant has 30 days from the policy mail date to return the delivery requirements to
the Home Office.
On the 25th day, a reminder notice is sent to the agent.
On the 35th day, a reminder notice is sent to the agent and the applicant.
On the 40th day, a final NTO notice is generated along with an invoice for any premium
that was submitted.
On the 45th day, the Policy Issue Department mails the refund check and letter of
explanation to whoever submitted the premium with the application.
After the 45th day from policy mail date:
A new application must be submitted and applicants must request a plan different from
the original application.
A new policy number will be assigned.
ACMIC might offer a short-term application to ensure coverage during this interim time
period.
Changes to a Pending Policy
If the applicant requests a change in plan of health insurance, deductibles, benefits, or
effective date while the policy is in underwriting, the agent should notify Medical
Underwriting to make a change on a pending application. Changes in plan, amount, or
benefits require signed amendments to the policy.
Changes to an Active Policy
The following plan and/or benefit changes require new applications and underwriting:
Change to a new plan that is currently marketed.
Change in deductible on an existing policy.
Change in co-insurance benefit on an existing policy.
If an individual is declined new insurance, ridered, or rated on the new plan being applied
for, that person can keep the original policy coverage as long as premiums have been paid.
When a new policy plan is applied, the original coverage should not be canceled and all
premiums should be paid to ensure continued coverage until the new plan has been approved
and the policy delivered.
American Community Mutual Insurance Company
Rev. April 2005
8-4
After the Applicant Has Signed
Example: A family could submit an application for a new policy. If one family member was
declined or offered an exclusion rider, this family member could stay with the original or
existing policy, and the remainder of the family could accept the new policy, which has a
new number and a new pre-existing period.
Withdrawn Applications
If the applicant is no longer interested in pursuing the application, the agent should notify the
state assigned underwriting assistant in Medical Underwriting. The request to withdraw must
be in writing by the agent or applicant.
Closing Underwriting Pending Files
A file will be closed and the application considered closed as incomplete, and premiums
refunded, if outstanding underwriting requirements have not been received within 60 days of
the underwriting request. The application will be reopened on a non-prepaid basis if the
outstanding requirements are received within 90 days of the application date. After 90 days, a
new application and full medical disclosure are needed.
Rated or Declined Applications
The applicant will receive a notice of explanation that documents the action taken and
provides the exact reason(s) for a rated offer or a declination. If the reason for the decline is
highly confidential such as HIV status, the reason will note the abnormal lab work only.
Applicants can access all documents by requesting copies in writing. The agent receives an
advance copy of the rated offer or decline letter.
As a business associate of ACMIC, the agent can access Protected Health Information
regarding their clients. This information is intended to help the agent in servicing the
applicant’s needs. However, federal and state laws and regulations are specific that the agent
must have a need to know the information. ACMIC will only share information with the
agent if there is a legitimate need to know or the applicant requests that the information be
shared.
Rev. April 2005
American Community Mutual Insurance Company
9 Appeals
Rated or Declined Applications
The applicant will receive a notice of explanation that documents the action taken and
provides the reason(s) for a rated offer or a declination. The reconsideration date and
requirements will be included if available.
Adverse Underwriting Determinations
in Arizona, Illinois, and Ohio
Arizona, Illinois and Ohio have enacted a requirement that any adverse underwriting
determination be accompanied by a special notice to the applicant.
Adverse underwriting decision means the following:
•
•
•
•
•
A decline in insurance coverage.
A termination of insurance coverage.
Failure of an agent to apply for insurance coverage with a specific insurance institution
which the agent represents and which is requested by an applicant.
An offer to insure at higher than standard rate.
An offer to insure with one or more exclusion riders.
A declination of insurance coverage solely because the coverage is not available on a class or
statewide basis or the rescission of a policy is not considered an adverse underwriting
decision, but American Community Mutual Insurance Company (ACMIC) must provide the
applicant or policyholder with the specific reason for this occurrence.
At the time of an adverse underwriting decision, ACMIC shall provide in writing the
following information to the applicant, policyholder or individual proposed for coverage:
The specific reason for the adverse underwriting decision.
The specific items of personal and privileged information that support those reasons.
However, ACMIC is not required to furnish specific items of privileged information if it
has reasonable suspicion, based upon specific information available for review by the
American Community Mutual Insurance Company
Rev. April 2005
9-2
Appeals
director, that the applicant, policyholder or individual proposed for coverage has engaged
in criminal activity, fraud, material misrepresentation or material nondisclosure. Further,
at ACMIC’s option, specific items of medical record information supplied by a medical
care institution or medical professional can be directly disclosed to the individual about
whom the information relates or to a medical professional designated by the individual
and licensed to provide medical care with respect to the condition to which the
information relates.
The names and addresses of the institutional sources that supplied the specific items of
information that support the reasons for the adverse underwriting decision. The identity
of any medical professional or medical care institution can be disclosed directly to the
individual or to the designated medical professional, whichever ACMIC prefers.
The applicant’s right to copies of the information used to make the underwriting
determination and provide the procedure for correcting inaccurate information.
If an adverse underwriting decision results solely from an oral request or inquiry, the
explanation of reasons and summary of rights may be given orally.
Appeals and Disclosing Information
Appeals
Under federal and state laws and regulations, the applicant has the right to access any
Protected Health Information (PHI) gathered by the Underwriting Department. The applicant
may only request their own information or that of their minor child. The request must be
made in writing. Copies of the PHI will be sent directly to the applicant at the address listed
on the application. Agents must be aware that highly confidential information such as lab
work showing positive HIV, records revealing drug use, etc will not be released to the agent
without specific instruction to do so by the applicant.
All applicants can appeal declines, rescissions, ratings, and riders. This appeal must be made
in writing and state the exact reason why the applicant feels the underwriting determination is
not accurate. Applicants who call the Home Office to appeal decisions will be directed to
contact their agent or submit their appeal in writing to Medical Underwriting. Responses to
appeals received in writing will be answered promptly in writing to the applicant.
In the states of Illinois, Indiana, Michigan, Missouri, and Nebraska, appeals of rescissions
will be treated as a grievance under state regulation and will follow the formal grievance
procedure.
Removal of Riders/ Smoking Ratings
The applicant may request removal of an exclusion rider from an existing health policy by
submitting the appropriate Application for Removal of Exclusion Rider to Medical
Rev. April 2005
American Community Mutual Insurance Company
Appeals
9-3
Underwriting. Reconsideration is available no sooner than the second policy anniversary for
Health insurance exclusion riders. Some exclusion riders might require longer
reconsideration periods and some will not be reconsidered. Usually if a rider was attached to
the policy for an indefinite period of time it will not be reconsidered.
When a health policy is issued with a substandard rating, the applicant may request
reconsideration after 12 months if a timeframe has not been designated by Underwriting.
This request must be submitted on an Application for Removal of Exclusion Rider (as
mentioned above), or on a current application. A full underwriting evaluation will be
undertaken.
When a health policy is issued with a rating for smoking the applicant may request
reconsideration after 12 consecutive months of non-smoking. All requests for reconsideration
of the smoking rating require submission of an Application for Removal of Exclusion Rider
or a current application, urine specimen and an evaluation of significant current health
smoking-related medical factors. The request will be fully underwritten but the effective date
of the policy will not change.
In-force health policies with effective dates prior to July 1, 1997 cannot be re-underwritten
for non-smoker rates unless a new plan of insurance is applied for with full new underwriting
requirements.
A letter will be sent to the agent advising of ACMIC’s action when a rider or (smoking)
rating is removed, revised or reduced. Written notification, for the insured’s records, will be
sent to the insured. Rating reduction or rider revision or removal will not generate new
schedule pages. However, an endorsement to the policy will be sent to the policyholder if an
exclusion rider is removed or revised, or the rating is reduced.
American Community Mutual Insurance Company
Rev. April 2005
9-4
Appeals
Rev. April 2005
American Community Mutual Insurance Company
A Contact Information
Customer Service Representative
T: 800-991-2642
Option 2 – Premium Payments
Individual New Business
F: 734-853-3117
Individual Underwriters
T: 800-991-2642 ext 4040
Individual Underwriting Assistants
T: 800-991-2642 ext 4722
Marketing Services Department
T: 800-233-3444
Option 3: To order software that illustrates Preferred, Standard, and Special Class
Health ratings.
F: 734-591-4628
National Sales Desk
T: 800-233-3444 (general)
800-991-2642 ext. 4717 To request the instructions on establishing a link to the online
short-term application.
Policy Issue Department
F: 734-591-4697 (permanent applications)
F: 734-853-3226 (short-term applications)
Supply Center
F: 734-853-3235
American Community Mutual Insurance Company
Rev. April 2005
A-2
Contact Information
Rev. April 2005
American Community Mutual Insurance Company
B Forms, Questionnaires,
and Surveys
Health Application Checklist
Applicant’s (proposed insured) full legal name and signature should be identical.
If short-term is applied for, indicate Effective Date and coordinate with Renewable Plan
Effective Date.
Only one selection can be chosen for Coverage Applied For.
Premium Payable should be indicated.
If Replacement is answered “yes”, make sure all questions are complete. Attach Replacement
Notice to application if required by state specific regulation (see Exhibit D).
Attach Replacement Forms to application.
Applicant’s (proposed insured) medical history.
NOTE:
These questions apply to each person proposed for insurance, including children.
If any medical questions are answered “yes”, details must be provided. Do not advise the
applicant that ACMIC will order an APS to obtain the details. Do not assume the underwriter
knows about claims on other ACMIC policies. The applicant must list past medical
conditions.
Applicant’s (proposed insured) personal physician.
Check all places for Applicant’s (proposed insured) and agent’s signatures to make sure they
are present.
NOTE:
Any changes or corrections on the application must be initialed and dated by the
Applicant (proposed insured), not the agent.
American Community Mutual Insurance Company
Rev. April 2005
List of Applications, Forms, and Questionnaires
Applications, Forms, and Questionnaires Sorted by Name
Name
State Stock Number
Filed Form Number
ACMIC List Billing Agreement
1605-0118
-
Addendum to the Application
2525-0343
33-104 694 2/02
Alcohol & Drug Questionnaire
5505-0276 R1
33-ADQ
Allergy/Asthma Questionnaire
5505-0277 R1
33-AAQ
Application for American Community Mutual Insurance Company Individual Health Insurance
AZ
IL
IA
IN
MI
MO
NE
OH
Application for Removal of Exclusion Rider
Arthritis Questionnaire
AZ
IL
IN
MI
MO
OH
NE
HA-1 AZ 6/04
HA-1 IL 6/04
TBD
HA-1 IN 6/04
HA-1 MI 3/04
HA-1 MO 6/04
HA-1 NE 6/04
HA-1 OH 6/04
2525-0220
2525-0220
2525-0220
2525-0220
2525-0220
2525-0220
2525-0220
33-133-606 4/93
33-133-606 4/93
33-133-606 4/93
33-133-606 4/93
33-133-606 4/93
33-133-606 4/93
33-133-606 4/93
5505-0016
33-ARQ
Aviation/Avocation Supplemental Questionnaire to Application
5505-0375
33-140
Digestive/Ulcer Questionnaire
5505-0017
33-DUQ
Ear/Otitis Questionnaire
5505-0018
33-EAQ
Foreign Residence/Travel Questionnaire
5505-0280
33-96-8-87
Gastrointestinal Questionnaire
5505-0019
33-GIQ
Illinois Application for Non-Renewable Short Term Major Medical Expense Policy
600A IL 1/05
-
Indiana Application for Non-Renewable Short Term Major Medical Expense Policy
600A IN 1/05
-
Kidney/Urinary Questionnaire
5505-0020
33-KUQ
Mental Health Questionnaire
5505-0021
33-MHQ
Michigan Application for Non-Renewable Short Term Major Medical Expense Policy
600A MI 1/05
-
Migraine/Headache Questionnaire
5505-0022
33-MIQ
Missouri Application for Non-Renewable Short Term Major Medical Expense Policy
ITP ST 1/05
-
Nebraska Application for Non-Renewable Short Term Major Medical Expense Policy
600A NE 1/05
-
AZ
IL
IA
IN
MI
MO
NE
OH
2525-0066 R1
2525-0073
TBD
2525-0073
33-HIV-AZ Rev 7/03
33-110 680 Rev 7/03
TBD
33-110 680 Rev 7/03
2525-0067 R1
2525-0073
2525-0068 R1
33-HIV-(MO) Rev 7/03
33-110 680 Rev 7/03
HIV-OH Rev 7/03
OH
600A OH 1/05
-
Notice and Consent for Blood Testing
Ohio Application for Non-Renewable Short Term Major Medical Expense Policy
American Community Mutual Insurance Company
Rev. April 2005
Forms, Questionnaires, and Surveys
B-3
Reinstatement
AZ
IA
IL
IN
MI
MO
NE
OH
-
33-27-H-AZ 6/03
33-27-H-IA 1/05
33-27-H-IL 6/03
33-27-H 6/03
33-27-H-MI 6/03
33-27-H-MO 6/03
33-27-H 6/03
33-27-H 6/03
Replacement Notice
AZ
IL
IA
IN
MI
MO
NE
OH
No form needed for individual
RAS-IL (2002) 2525 0077 R1
RAS-IA
No form needed for individual
No form needed for individual
No form needed for individual
No form needed for individual
No form needed for individual
Request for Deduction of Monthly Premiums from Salary
1605-0117
-
Request to Re date Health Insurance Policy
-
33-144-771 1/98
Seizure/Epilepsy Questionnaire
5505-0023
33-SEQ
Spinal Questionnaire
5505-0024
33-SPQ
Thyroid Questionnaire
5505-0025
33-THQ
Tumor/Cyst Questionnaire
5505-0026
33-TCQ
Applications, Forms, and Questionnaires Sorted by State
Name
Stock Number
Filed Form Number
Relevant to All States
ACMIC List Billing Agreement
Addendum to the Application
Alcohol & Drug Questionnaire
Allergy/Asthma Questionnaire
Arthritis Questionnaire
Aviation/Avocation Supplemental Questionnaire to Application
Digestive/Ulcer Questionnaire
Ear/Otitis Questionnaire
Foreign Residence/Travel Questionnaire
Gastrointestinal Questionnaire
Kidney/Urinary Questionnaire
Mental Health Questionnaire
Migraine/Headache Questionnaire
Request for Deduction of Monthly Premiums from Salary
Request to Re date Health Insurance Policy
Seizure/Epilepsy Questionnaire
Spinal Questionnaire
Thyroid Questionnaire
Tumor/Cyst Questionnaire
1605-0118
2525-0343
5505-0276 R1
5505-0277 R1
5505-0016
5505-0375
5505-0017
5505-0018
5505-0280
5505-0019
5505-0020
5505-0021
5505-0022
1605-0117
5505-0023
5505-0024
5505-0025
5505-0026
33-104 694 2/02
33-ADQ
33-AAQ
33-ARQ
33-140
33-DUQ
33-EAQ
33-96-8-87
33-GIQ
33-KUQ
33-MHQ
33-MIQ
33-144-771 1/98
33-SEQ
33-SPQ
33-THQ
33-TCQ
Arizona
Application for American Community Mutual Insurance Company Individual Health Insurance
HA-1 AZ 6/04
Application for Removal of Exclusion Rider
2525-0220
33-133-606 4/93
Notice and Consent for Blood Testing
2525-0066 R1
33-HIV-AZ Rev 7/03
Reinstatement
33-27-H-AZ 6/03
Replacement Notice
No form need for individual
American Community Mutual Insurance Company
Rev. April 2005
Forms, Questionnaires, and Surveys
B-5
Illinois
Application for American Community Mutual Insurance Company Individual Health Insurance
HA-1 IL 6/04
Application for Removal of Exclusion Rider
2525-0220
Illinois Application for Non-Renewable Short Term Major Medical Expense Policy
600A IL 1/05
Notice and Consent for Blood Testing
2525-0073
Reinstatement
Replacement Notice
RAS-IL (2002)
33-133-606 4/93
33-110 680 Rev 7/03
33-27-H-IL 6/03
2525 0077 R1
Indiana
Application for American Community Mutual Insurance Company Individual Health Insurance
HA-1 IN 6/04
Application for Removal of Exclusion Rider
2525-0220
33-133-606 4/93
Indiana Application for Non-Renewable Short Term Major Medical Expense Policy
600A IN 1/05
Notice and Consent for Blood Testing
2525-0073
33-110 680 Rev 7/03
Reinstatement
33-27-H 6/03
Replacement Notice
No form need for individual
Iowa
Application for American Community Mutual Insurance Company Individual Health Insurance
TBD
Notice and Consent for Blood Testing
TBD
Reinstatement
Replacement Notice
RAS-IA
TBD
33-27-H-IA 1/05
-
Michigan
Application for American Community Mutual Insurance Company Individual Health Insurance
HA-1 MI 3/04
Application for Removal of Exclusion Rider
2525-0220
33-133-606 4/93
Michigan Application for Non-Renewable Short Term Major Medical Expense Policy
600A MI 1/05
Notice and Consent for Blood Testing
TBD
TBD
Reinstatement
33-27-H-MI 6/03
Replacement Notice
No form need for individual
Missouri
Application for American Community Mutual Insurance Company Individual Health Insurance
HA-1 MO 6/04
Application for Removal of Exclusion Rider
2525-0220
33-133-606 4/93
Missouri Application for Non-Renewable Short Term Major Medical Expense Policy
ITP ST 1/05
Notice and Consent for Blood Testing
2525-0067 R1
33-HIV-(MO) Rev 7/03
Reinstatement
33-27-H-MO 6/03
Replacement Notice
No form need for individual
Nebraska
Application for American Community Mutual Insurance Company Individual Health Insurance
HA-1 NE 6/04
Application for Removal of Exclusion Rider
2525-0220
33-133-606 4/93
Nebraska Application for Non-Renewable Short Term Major Medical Expense Policy
600A NE 1/05
Notice and Consent for Blood Testing
2525-0073
33-110 680 Rev 7/03
Reinstatement
33-27-H 6/03
Replacement Notice
No form need for individual
Ohio
Application for American Community Mutual Insurance Company Individual Health Insurance
HA-1 OH 6/04
Application for Removal of Exclusion Rider
2525-0220
33-133-606 4/93
Notice and Consent for Blood Testing
2525-0068 R1
HIV-OH Rev 7/03
Ohio Application for Non-Renewable Short Term Major Medical Expense Policy
600A OH 1/05
Reinstatement
33-27-H 6/03
Replacement Notice
No form need for individual
American Community Mutual Insurance Company
Rev. April 2005
Forms, Questionnaires, and Surveys
B-7
B-8
Forms, Questionnaires, and Surveys
Rev. April 2005
American Community Mutual Insurance Company
Glossary
ACMIC
American Community Mutual Insurance Company
Agent
Field underwriter.
APS
See Attending Physician Statement
Application
The application is part of the policy/certificate to which is
attached, and is therefore part of the legal contract between
American Community Mutual Insurance Company (ACMIC)
and the client. The application is subject to all the terms and
conditions of the policy/certificate not inconsistent with it.
Incorrect versions of applications cannot be processed and
must be returned to the agent. There are four types of
applications and forms: short-term, prescreen, permanent, and
reinstatement.
Attending Physician
Statements
See medical records.
Certificate
Term used in Missouri for Policy.
Change
A modification of an in force policy.
COBRA
The Consolidated Omnibus Budget Reconciliation Act of 1985,
which allows an employee and/or family member to continue
their group health plan enrollment when coverage is
mandatorily lost. Examples of mandatory loss of coverage
include separation from employment, marriage of a dependent,
a dependent attaining age 23, divorce or legal separation.
Coverage can continue at a cost of 102 percent of the premium
for a period of 18 months for an employee and a period of 36
months for a dependent.
Commingling of funds
Commingling of funds is the placing of another’s money in any
type of an account controlled by the agent. This is strictly
prohibited. All transactions involving the transfer of funds
should be handled accurately and promptly.
American Community Mutual Insurance Company
Rev. April 2005
G-2
Glossary
Declined
Coverage is declined when ACMIC determines that an
applicant is too high of a risk to insure, or there are
circumstances that require voiding the application (e.g.,
Misrepresentation). See also Rejected.
Dependent
A spouse; unmarried children who are at least 15 days old and
have not yet reached their 22nd birthday, including stepchildren, and legally adopted children who are legally
dependent on the applicant; and grandchildren who are in the
legal custody of their grandparents. Coverage of newborn and
adopted children is automatic and continues for 31 days,
provided at least one adult family member is insured on the
existing policy/certificate.
Effective date
The date on which the ACMIC policy is in force.
Exclusion rider
An addition to a policy/certificate that excludes a medical
condition, vocation, avocation, or a combination of one or
more conditions from coverage.
Field underwriter
Former term for agent.
Full-time student
Dependents between the ages of 19 and 22 years old who are
enrolled at an accredited college, university, or secondary trade
school; enrolled for a minimum of 12 credit hours; and be
dependent upon the primary insured for at least 50% of their
financial support.
HA-1
The basic application used to apply for a permanent insurance
policy. There is a different HA-1 for each state in which
ACMIC is licensed to provide coverage. The HA-1 cannot be
used as a reinstatement application
HIPAA
The Health Insurance Portability and Accountability Act, also
known as Kassebaum-Kennedy, after the two senators who
spearheaded the bill. HIPAA is a federal law designed to allow
the portability of health insurance between jobs. Generally,
HIPAA restricts the use of preexisting condition exclusions,
creates special enrollment periods and prohibits discrimination
based on health-status related conditions in enrollment and
premiums. HIPAA also creates an obligation for most group
health plans or their insurers to provide certificates of
creditable coverage to individuals who ceased to be covered by
Rev. April 2005
American Community Mutual Insurance Company
Glossary
G-3
a group health plan. In addition, it required the creation of a
federal law to protect personally identifiable health
information; if that did not occur by a specific date (which it
did not),
Key applicant
The applicant in whose name the policy will be issued.
List bill
List bills are individual health policies/certificates being billed
on one billing notice to an employer. All individual
policies/certificates have a common billing date. There must be
a minimum of three applicants to accept a list bill.
Long-term
Former term for permanent application and coverage.
Medical records
Written records from various health care providers regarding
such issues as health complaints, symptoms, conditions,
diagnoses, treatments, and recommendations.
Misrepresentation
To knowingly give a false or misleading information, usually
with intent to deceive or be unfair during the underwriting
process.
NTO
Not Taken Out. The policy has been issued and mailed, but the
applicant decided not to accept the policy or did not complete
the delivery requirements necessary to activate the policy.
Paramedical examination
These examinations consist of medical information, height,
weight, blood pressure, blood profile, and urine specimen. A
list of tests included in the blood profile can be found in
chapter 7 - “Risk Selection”, in the “Paramedical
Examinations” section.
Permanent application
Permanent applications are used to apply for a
policy/certificate that will be kept in place for at least one year.
Also known as a long-term application. Permanent applications
cannot be used as a reinstatement application See also HA-1.
PHI
See Protected Health Information.
Policy
See also Certificate.
PPO
See Preferred Provider Organization .
American Community Mutual Insurance Company
Rev. April 2005
G-4
Glossary
Preferred Provider
Organization
An organization providing health care that gives
economic incentives to the individual purchaser of a healthcare contract to patronize certain physicians, laboratories, and
hospitals that agrees to supervision and reduced fees. See also
HMO.
Prescreen application
Agents can use prescreen forms to quickly receive an
underwriting assessment of risk based on minimal medical
information. The prescreen form is one page long. A prescreen
form can be completed entirely by an agent and does not
require the applicant’s signature. Also known as a prospect
form.
Proposal
An estimated policy rate provided by the agent based on the
client’s demographics. It should be submitted with the
application. A proposal does not take into consideration health
history. See also Quote.
Protected Health
Information
Protected health information (PHI) under HIPAA means
individually identifiable health information. Identifiable refers
not only to data that is explicitly linked to a particular
individual (that's identified information). It also includes health
information with data items, which reasonably could be
expected to allow individual identification. the definition of
PHI excludes individually identifiable health information in
education records covered by the Family Educational Right and
Privacy Act. It also excludes employment records held by a
covered entity in its role as employer
Quote
An offer of coverage based on an underwriting assessment of
risk as determined by information provided by the applicant
and/or requested by the underwriter (e.g., medical records,
paramedical exam, etc.). See also Proposal.
Rejected
A policy is rejected when it cannot be processed due to errors
on the application or information missing from the application.
See also Declined.
Reinstatement
application
Reinstatement applications are used for any
policy/certificate that has lapsed more than 31 days, but less
than 12 months where the applicant wishes to apply for the
same product, deductible, coinsurance, and options as the
original policy/certificate
Rev. April 2005
American Community Mutual Insurance Company
Glossary
G-5
Replacement policy
Replacing health insurance is defined as any transaction in
which a new accident and health insurance is to be purchased;
and it is known to the agent, broker, or insurer at the time of
the application that, as part of the transaction, existing accident
and health insurance has been or is to be lapsed or the benefits
substantially reduced
Rewrite
Rewriting health insurance is defined as any transaction in
which a current ACMIC policy/certificate holder wants to
apply for a new plan of insurance or change benefits, and can
qualify within the risk selection requirements.
Rider
See exclusion rider.
Risk selection
Lists of common medical conditions, occupations, and
avocations with their associated underwriting actions.
Schedule Page
A schedule page includes the plan of insurance, the deductible,
the co-pay, and any applicable options that are selected.
Segmented application
Segmented applications occur when an applicant completes or
signs an application in parts without access to the total
document. Segmentation can put an agent’s E&O insurance at
risk and/or the application could be considered falsified.
Short-term
Short-term applications are an interim health insurance plan for
individuals transitioning from one permanent health plan to
another. Short-term applications are used to apply for coverage
of less than one year and is not renewable.
Signature
The handwritten, legal name of the applicant(s) or agent as
they appear on the application/survey. See also Signature date.
Signature date
The date the signature is written on the application or
accompanying forms/surveys. See also Signature.
Underwriting
The ultimate goal of underwriting is to fairly and accurately
place each insured into a broad risk category with appropriate
morbidity and mortality/claims expectations.
Withdrawn application
An application withdrawn prior to the effective date. The
request to withdraw must be in writing by the agent or
applicant.
American Community Mutual Insurance Company
Rev. April 2005
G-6
Glossary
Rev. April 2005
American Community Mutual Insurance Company
Index
A Summary of Your (Privacy) Rights 4-14
ACMIC Web site 1-1, 1-3, 4-10, 5-2, 8-1
acne
7-12
adding dependents
1-4, 6-1
adopted child coverage
6-2
agents
appointing
1-1, 4-1
licensing
1-1, 4-1, 9-2
paying premiums
2-4, 4-6
alcohol use 1-3, 1-5, 2-2, 4-13, 7-3, 7-12,
See also DUI and DWI
alkaline phosphatase
7-3
allergies
7-13
anemia
7-13
anxiety
7-13
appeals
9-2
applications
dating
1-1, 4-1
errors
2-3, 4-3, 4-15, 5-4, 5-5
faxing
4-16, 8-1
online
1-3, 2-1, 2-3, 2-5, 2-6
permanent 1-1, 1-3, 1-4, 1-5, 2-1, 2-3, 24, 3-1, 3-2, 4-1 - 4-18, 5-4, 5-5, 6-2, 71, 7-30, 7-32, 8-1
prescreen form 1-1, 1-3, 3-1, 3-2, 4-11,
7-1
reinstatement
1-1, 5-1 - 5-6
segmented
4-16
short-term 1-1, 2-1 - 2-6, 4-11, 6-2, 7-6,
7-30, 8-1, 8-3
signing 1-3, 2-2, 2-3, 3-1, 4-2, 4-3, 4-4,
4-7, 4-11, 4-12, 4-13, 4-15, 4-16, 4-17,
5-4, 5-5, 5-6, 5-7, 8-1
soliciting
1-1, 4-1, 4-4
submitting
4-16
taking 1-1, 2-4, 3-1, 4-1, 4-6, 4-13, 8-4,
9-1
withdrawn
8-4
appointing agents
1-1, 4-1
Arizona
adverse underwriting determinations 9-1
exclusion riders
7-1
foreign travel
7-32
HIPAA
1-4, 4-5
reinstatement
5-2
risk selection
7-12 - 7-19
Armed Forces
7-30
arthritis
7-13
asbestos workers
7-30
asthma
7-13
ATVs
7-30, 7-31
Australia
exchange students
7-31
foreign-born nationals
7-32
short-term qualifications
1-3, 2-2
authorization to obtain protected health
information (PHI)
4-14, 5-6
Aviation/Avocation Supplemental
Questionnaire to Application
7-31
back and spine disorders
7-14
Bell’s Palsy
7-15
benefits
changing
1-5
paying
1-4
bilirubin
7-3
blood analysis
7-2
blood urea nitrogen (BUN)
7-3
boaters
7-31
bronchitis
7-16
build chart See health insurance build chart
Caesarean section
7-16
American Community Mutual Insurance Company
Rev. April 2005
I-2
Index
Canada
citizens temporarily residing in the
United States
7-31
foreign-born nationals
7-32
short-term qualifications
1-3, 2-2
carnival and circus workers
7-30
Carpal Tunnel Syndrome
7-16
changing
active policy
8-3
benefits
1-5
coverage
1-4
pending policy
8-3
checks
2-4, 4-6, 4-7
chemical workers
7-30
cholesterol
7-3, 7-4, 7-16
Chronic Fatigue Syndrome
7-16
claims
1-5, 1-6, 4-2, 5-3, 7-1, 8-2
cleft palate
7-16
closing underwriting pending files
8-4
COBRA
4-5, 4-11
coinsurance
1-6
colitis
7-17
commingling of funds
2-4, 4-6
commission
1-1, 4-1
contestability period
1-5
correcting errors 2-3, 4-3, 4-15, 5-4, 5-5
correctional institution employees
7-30
coverage
changing
1-4
delivering outline in Illinois
8-2
dependents
2-3, 4-15, 5-6
lapsed
1-4, 1-6, 5-1, 5-4
newborns and adopted children 6-1, 6-2
permanent 1-1, 1-3, 1-4, 1-5, 2-1, 2-3, 24, 3-1, 3-2, 4-1 - 4-18, 5-4, 5-5, 6-2, 71, 7-30, 7-32, 8-1
replacing
1-4, 4-4
rewriting
1-5, 1-6, 2-1, 4-12
short-term 1-1, 2-1 - 2-6, 4-11, 6-2, 7-6,
7-30, 8-1, 8-3
transitioning
1-3, 2-1
creatinine
7-3
Credible Coverage
4-5
Rev. April 2005
credit cards
2-3, 2-4, 2-5, 4-7
crop dusters
7-30
Customer Service Center
8-2
Customer Service Line
4
date/time errors
2-3, 4-3, 4-15, 5-4, 5-5
dating applications
1-1, 4-1
deafness
7-17
declined applications 2, 1-3, 1-6, 2-2, 4-5,
5-2, 7-4, 7-6, 7-12, 8-3, 8-4, 9-1
demolition workers
7-30
Department of Motor Vehicles
7-5
dependents
adding
1-4, 6-1
adopted children
6-1
coverage
2-3, 4-15, 5-6
grandchildren
6-1
newborn
6-1
removing
6-2
signature requirements
2-3
step-children
6-1
depression
7-13
detectives
7-30
deviated nasal septum
7-17
disclosing pre-existing conditions 1-4, 1-5,
2-2, 2-4
diverticulitis
7-17
diving
7-31
downloading forms
4-10
drilling/exploration workers
7-30
drivers hauling explosives
7-30
drug use
1-5, 4-13
DUI
4-13
DWI
4-13, 7-10, 7-12
ear disorders
7-18
effective date1-4, 1-5, 2-1, 2-3, 2-6, 4-4, 411, 4-12, 4-13, 5-5, 8-2, 8-3, 9-3
Electronic Funds Transfer (EFT) 2-3, 2-4,
2-5, 4-6, 4-7, 4-8, 4-15, 8-1
England
foreign-born nationals
7-32
short-term qualifications
1-3, 2-2
entertainment industry employees
7-30
American Community Mutual Insurance Company
Index
errors on the application 2-3, 4-3, 4-15, 54, 5-5
esophagitis
7-19
Europe
exchange students
7-31
exchange students
7-31
exclusion rider 1-6, 4-12, 7-1, 7-12, 7-31,
8-2, 8-4, 9-2, 9-3
exclusionary period
7-1
explosives workers
7-30
faxing applications
4-16, 8-1
federal regulations
7-2, 8-4, 9-2
fibromyalgia
7-19
firefighters
7-30
fissure
7-19
foreign travel
1-3, 2-2, 7-31, 7-32
foreign-born nationals
7-32
forms
downloading
4-10
prescreen
1-1, 1-3, 3-1, 3-2, 4-11, 7-1
replacement
1-4, 4-4
foundry workers
7-30
fracture
7-19
full mode premium
2-5, 4-6, 4-7
gallbladder
7-19
gamma-glutamyl transpedtidase (GGT) 73, 7-4
ganglion cyst
7-20
gastritis
7-20
glucose
7-3
government agency employees
7-30
grace period
1-6, 5-1
grandchildren
4-1, 6-1
guardians
2-3, 4-14, 4-15, 5-6, 6-1
gynecological disorders
7-20
headaches
7-22
health insurance build chart
7-8
Health Insurance Privacy and Portability
Act (HIPPA) 1-4, 4-2, 4-4, 4-5, 4-6, 411, 4-14, 5-6, 5-7, 7-2, 7-6
health savings account
4
hearing impairment
7-18
hemorrhoids
7-22
I-3
HIPAA
privacy regulations
4-14, 5-6, 5-7
state-specific regulations
1-4, 4-5
HIV
7-2, 7-4, 7-5, 7-11, 8-4, 9-2
HIV Consent From
7-2, 7-4
hypertension
7-22
hypoglycemia
7-22
Illinois
adverse underwriting determinations 9-1
appeals
9-2
exclusion riders
7-1
health replacement form
1-4, 4-4
HIPAA
4-5
outline of coverage required
8-2
reinstatement
5-2
risk selection
7-12 - 7-19
short-term coverage
2-1
state health plan
1-6
Indiana
appeals
9-2
exclusion riders
7-1
HIPAA
4-5
reinstatement
5-2
risk selection
7-12 - 7-19
short-term coverage
2-1
state health plan
1-6
Individual Administration System 4, 2-1,
4-4
interaction of multiple medical conditions
1-3, 3-1
Iowa
exclusion riders
7-1
health replacement form
1-4, 4-4
HIPAA
4-5
reinstatement
5-2
short-term coverage
2-1
state health plan
1-6
Ireland
foreign-born nationals
7-32
short-term qualifications
1-3, 2-2
key applicant 2-3, 4-1, 4-2, 4-14, 4-15, 5-4,
5-6, 6-1
kidney disorders
7-22
American Community Mutual Insurance Company
Rev. April 2005
I-4
Index
lactic dehydrogenase (LDH)
7-4
lapsed policy/certificate 1-4, 1-5, 4-9, 4-11
lapsed premiums
1-6
lapsing coverage
1-4, 1-6, 5-1, 5-4
licensing agents
1-1, 4-1, 9-2
liquor industry workers (bars and lounges)
7-30
List Billing Agreement and Request for
Deduction of Monthly Premiums from
Salary
4-9
list bills
adding new insureds
4-9
creating
4-8
paying
4-8
removing insureds
4-9
logging industry workers
7-30
Lyme Disease
7-23
Marketing Support Specialist
1-3
martial arts
7-31
Medicaid
4-5
medical and non-medical underwriting
questions
5-4
medical history
7-2, 7-3, 7-4
medical questionnaire
7-5
medical records
3-1, 7-1, 7-2, 7-5
Medical Underwriting Department
3
Medicare
4-5
Michigan
appeals
9-2
exclusion riders
7-1
HIPAA
4-5
HIV consent forms
7-2
reinstatement
5-2
risk selection
7-12 - 7-19
short-term coverage
2-1
state health plan
1-6
migraines
7-22
miners
7-30
misrepresentation
1, 2
missionary workers
7-31
Missouri
appeals
9-2
contraceptive opt-out
4-10
Rev. April 2005
dependent signature requirements 4-14,
4-15, 5-6
exclusion riders
7-1
HIPAA
1-4, 4-5
minors on applications
5-4, 6-1
reinstatement
5-2
risk selection
7-12 - 7-19
short-term coverage
2-1
money orders
2-4, 4-6, 4-7
motion picture industry personnel
7-30
motorcycles
7-30, 7-31
mountain and rock climbing
7-31
National Sales Office 3, 4, 1-1, 1-3, 1-5, 22, 2-6, 3-2, 4-8, 4-10, 5-2
Nebraska
appeals
9-2
exclusion riders
7-1
HIPAA
4-6
reinstatement
5-2
risk selection
7-12 - 7-19
short-term coverage
2-1
state health plan
1-6
New Zealand
exchange students
7-31
foreign-born nationals
7-32
short-term qualifications
1-3, 2-2
newborn child coverage
6-1
non-medical questionnaire
7-5
non-US citizens
7-31
Not Taken Out (NTO)
4-2, 8-3
Notice of Insurance Information Practices
4-14
notices
1-4
Notification of Investigation
4-14
NTO
See Not Taken Out
Ohio
adverse underwriting determinations 9-1
exclusion riders
7-1
HIPAA
1-4, 4-6
reinstatement
5-2
risk selection
7-12 - 7-19
short-term coverage
2-1
online application 1-3, 2-1, 2-3, 2-5, 2-6
American Community Mutual Insurance Company
Index
osteoporosis
7-23
pancreatitis
7-24
paramedical examination
7-1, 7-2, 7-5
parents
2-3, 4-2, 4-14, 4-15, 5-6
paying
agents and premiums
2-4, 4-6
benefits
1-4
commission
1-1, 4-1
Peace Corp workers
7-31
permanent application 1-1, 1-3, 1-4, 1-5, 21, 2-3, 2-4, 3-1, 3-2, 4-1 - 4-18, 5-4, 5-5,
6-2, 7-1, 7-30, 7-32, 8-1
pilots
7-31
police personnel (patrol)
7-30
policies/certificates
changes to active
8-3
changes to pending
8-3
delivery procedures
8-1
delivery requirements
8-2
Policy Issue
2-4, 8-3
PPO network
4-10
pre-existing conditions 1-4, 1-5, 2-2, 2-4
pregnancy
7-24
premium due notices
2-5, 4-7
premiums
agents paying
2-4, 4-6
full mode
2-5, 4-6, 4-7
lapsed
1-6
paying by check or money order 2-4, 4-7
paying by credit card 2-3, 2-4, 2-5, 4-7
paying by list bill
4-8
selecting a billing option
2-4, 4-7
submitting
4-6
prescreen form 1-1, 1-3, 3-1, 3-2, 4-11, 7-1
private investigators
7-30
professional divers
7-30
professional or semiprofessional athletes 730
prostate disorders
7-24
questionnaires
7-5
racing
7-30, 7-31
rating
applicants
1-5
I-5
changes to an active policy
8-3
conditions
1-3, 2-4, 3-1
declined applications
8-4, 9-1
effective date
4-12
HIPAA
4-5, 7-6
lapsed policy/certificate
1-5
providing new premium illustration 8-2
reinstatement
5-2
smoking
7-4
special class
4-12
rectal disorders
7-24
Regional Marketing Director
3
regulations
federal
7-2, 8-4, 9-2
HIPAA privacy
4-14, 5-6, 5-7
state
1-1, 1-4, 1-6, 4-5, 7-2, 8-4, 9-2
reinstatement application
1-1, 5-1 - 5-6
removing dependents
6-2
replacement form
1-4, 4-4
replacement notices
1-4
replacing coverage
1-4, 4-4
reporting changes in health status
4-13
required notices
1-4
respiratory disorders
7-25
rewriting coverage
1-5, 1-6, 2-1, 4-12
rider 1-3, 1-5, 3-1, 3-2, 4-10, 4-11, 5-2, 54, 7-1, 7-6, 7-12, 7-16, 7-18, 8-2, 9-3
risk selection 1-5, 4-10, 4-11, 4-13, 7-1 - 730
roofers
7-30
Scandinavia
exchange students
7-31
Scotland
foreign-born nationals
7-32
short-term qualifications
1-3, 2-2
security personnel
7-30
segmented applications
4-16
selecting a billing option
2-4, 4-7
SGOT (AST)
7-4
SGPT (ALT)
7-4
short-term application 1-1, 2-1 - 2-6, 4-11,
6-2, 7-6, 7-30, 8-1, 8-3
American Community Mutual Insurance Company
Rev. April 2005
I-6
Index
signing applications 1-3, 2-2, 2-3, 3-1, 4-2,
4-3, 4-4, 4-7, 4-11, 4-12, 4-13, 4-15, 416, 4-17, 5-4, 5-5, 5-6, 5-7, 8-1
sinusitis
7-26
skiing
7-31
sky diving
7-31
smoking 3-1, 4-11, 7-4, 7-6, 7-13, 7-16, 722, 9-2, 9-3
soliciting applications
1-1, 4-1, 4-4
state regulations 1-1, 1-4, 1-6, 4-5, 7-2, 84, 9-2
state uninsurable health plans
1-6
status of underwriting
4
steel workers
7-30
students
7-31
stunt drivers
7-30
stunt performance
7-31
submitting applications
4-16
taking applications 1-1, 2-4, 3-1, 4-1, 4-6,
4-13, 8-4, 9-1
taxi drivers
7-30
Temporomandibular Joint Dysfunction 726
Ten Day Free Look provision
8-1
thyroid disorders
7-26
tobacco use
See smoking
tonsillitis
7-27
toxic materials wprlers
7-30
Rev. April 2005
transitioning coverage
1-3, 2-1
triglyceride
7-4
trusts
4-14
ulcers
7-27
unacceptable medical conditions
7-10
underwriting status
4
unemployed individuals
7-30
United States
Canadian citizens residing in
7-31
exchange students
7-31
foreign travel
7-31
foreign-born nationals
7-32
short-term qualifications
1-3, 2-2
students
7-31
urinary tract disorders
7-28
urine analysis
7-2
varicose veins
7-29
vertigo
7-29
Web site (ACMIC)
1-1, 4-10, 5-2, 8-1
withdrawn application
8-4
writing
permanent applications1-1, 1-3, 1-4, 1-5,
2-1, 2-3, 2-4, 3-1, 3-2, 4-1 - 4-18, 5-4,
5-5, 6-2, 7-1, 7-30, 7-32, 8-1
reinstatement applications 1-1, 5-1 - 5-6
short-term applications 1-1, 2-1 - 2-6, 411, 6-2, 7-6, 7-30, 8-1, 8-3
American Community Mutual Insurance Company
4657-0091 R1