Cm-603-47245_pew1206

Individual PlanMedical Underwriting Guidelines M U G
Insurability
Because of the potential additional risk associated with certain medical conditions, some Applicants will be declined for all
coverages. However, based on underwriting evaluation PacifiCare Individual PPO plans may be offered at a 20 percent or
50 percent additional premium. PacifiCare’s Individual HMO plans are not available for other than preferred premiums.
Ineligible Occupations
Structural steel workers, iron workers andsteeplejacks Window workers working at heights exceeding Unisex Height and Weight Table
The height and weight table included with these guidelines will be used to evaluate an Applicant’s insurability. Certainconditions, such as high blood pressure, as well as individuals that smoke, will be taken into consideration during theapplication process in conjunction with height and weight.
Prescription Medications
Depending on the plan selected, the prescriptions below may result in an application being declined. The cost of a medication is considered a part of the insurance risk, regardless of the severity of the condition itself.
The prescription list is intended to serve as a guide only; other prescriptions may result in an application being declined or if a PPO plan is selected, rated with an additional 20 percent or 50 percent of premium.
Declinable Conditions
Applicants with the following conditions will generally be considered uninsurable. This list is intended to serve as a guide only; decisions regarding an Applicant are subject to underwriting consideration of the facts related to a specific medical history. The absence of any impairmentfrom this list does not imply insurability.
Uninsurable Conditions:
Acne – Accutane free less than 6 months Acoustic Neuroma – unoperated or surgery within Anemia – Aplastic, Cooley’s, Hemolytic, Aneurysm – Cerebral (“Berry”) & Peripheral Artery – Anorexia Nervosa – treatment within 5 years Diabetes Mellitus – Insulin dependent and/or over 10years since diagnosed Bladder – treatment free for less than 5 years Brain – treatment free for less than 10 years Breast – treatment free for less than 7 years Cervix/Uterus, Ovary – treatment free for less than Colon – treatment free for less than 7 years Esophagus – treatment free for less than 10 years Eye – treatment free for less than 5 Years Hodgkin’s Lymphoma – treatment free for less Flexion Contracture, Upper Extremity, LPU Kidney – treatment free for less than 7 years Larynx – treatment free for less than 10 years Leukemia – treatment free for less than 10 years Liver – treatment free for less than 10 years Lung – treatment free for less than 10 years Oral Cavity, Pharynx – treatment free for less than Pancreas – treatment free for less than 10 years Prostate – treatment free for less than 10 years Skin – Basal/Squamous – multiple/ treatment free Skin – Melanoma – treatment free for less than 7 years Stomach – treatment free for less than 5 years Testicular – treatment free for less than 5 years Thyroid – treatment free for less than 5 years Chronic Fatigue Syndrome – within 5 years ofrecovery COPD (Chronic Obstructive Pulmonary Disease) Cleft Lip, Nose, Palate – not surgically corrected Coagulation Defect (Christmas Disease, Hemophilia A, Obesity – Prior or planned surgical procedure related Colitis/IBS – Crohn’s Disease, Ulcerative Colitis CAD – Angina Pectoris, Angioplasty, Heart Bypass, Additional Circumstances Requiring
Automatic Rejection
Therapy/Counseling – within the last 6 months Receiving disability payments or benefits Currently being treated for work-related disorder or Currently experiencing/experienced within the last 12 months symptoms for which a physician has not been Recommended diagnostic tests have not been Rescission
Subsequent to enrollment in a PacifiCare Individual Plan,PacifiCare reviews all claims submitted to identify medical conditions which may have not been accurately disclosed at the time of application. All such claims are referred to PacifiCare’s underwriting department for further investigation. While an investigation is being conducted,the original claim and all subsequent claims from all providers will be pended until the underwriting investigation is completed. If it is determined that an Applicant materially misrepresented medical history when the application was completed, the policy will be rescindedas of the original effective date and premiums will be refunded, net of any unrecoverable expenses. Broker commission is adversely affected by any retroactive cancellations. Any commissions paid on a policy that is rescinded will be charged back and collected from the broker.
P.O. Box 6006
Cypress, CA 90630
Customer Service:
800-624-8822
800-442-8833 (TDHI)
Visit our Web site @ www.pacificare.com
2003 by PacifiCare Health Systems, Inc.
CM-603-47245PEW1206

Source: http://www.consumerwatchdog.org/resources/PacifiCareUnderwriting.pdf