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How to Evaluate a Health Insurance Company

© Patricia Foote, May 2000

  • Does the plan provide for regular, preventive health exams?
  • Do preexisting medical conditions prevent full coverage? How long do you need to be enrolled before a preexisting condition will be covered?
  • Does the plan allow you a choice of physicians?
  • Are there any co-payments?
  • Which services need pre-approval? Who will authorize this pre-approval and how far in advance of the procedure does it need to be done?
  • How are participating physicians paid? Is there a capitation policy? (Capitation: a method of payment for health services in which a physician or hospital is paid a fixed per capita amount for each person served, regardless of the actual number or type of services provided to each person.)
  • Are there "gag clauses" that keep a doctor from recommending treatment or criticizing the plan?
  • Can you contact specialists directly or do you need a referral?
  • Does the plan provide a prescription drug benefit?
  • Does the plan include full reproductive health and pregnancy care?
  • Does the plan provide treatment for mental health problems? Is there a limit to the number of visits?
  • What are the deductibles and/or co-payments?
  • How are treatment decisions reviewed?
  • Is there an appeals process if a service is denied and what is it?
  • Are genetic tests covered?
  • What is the policy on experimental drugs and clinical trials?
  • What are the restrictions/benefits for emergency procedures?
  • Is coverage nationwide/worldwide?
  • What is the "medical-loss ratio" (the amount that the provider actually spends on medical care)?
  • Does this policy contain a catastrophic illness clause?
  • Is there a life-time cap on reimbursement payments? What is it? What services are not covered?
  • Is the insurance company registered and accredited? Contact: Group Health Association of America, 1129 20th St., N.W., Suite 600, Washington, D.C. 20038.
  • Read the review of managed care in America done by the National Committee for Quality Assurance.
  • Read "What Cancer Survivors Need to Know About Health Insurance" published by the National Coalition for Cancer Survivorship.
  • Add your own questions ....

Collecting Health Insurance Benefits:

  • Send your claims in on time. Most insurance companies have a time limit for submitting claims.
  • If you are too tired to work on bills yourself and noone else can do it, consider hiring a health claims processing service to do it for you.
  • Keep copies of all bills and correspondenced with the insurance company.
  • Submit bills in the proper order i.e. first to the primary insurer and then to the secondary insurer.


Patricia Foote is a trainer for Stanford University's "The Chronic Disease Self-Management Course" and is the author of How Are You? Manage Your Own Medical Journey, available from Amazon.com or local bookstores.


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