home Islamic April 2010 – Monthly Insurance Q&A

April 2010 – Monthly Insurance Q&A

Q: Can my employer stop my health care when on comp?
A: Yes unless you are on FMLA, CFRA or (CA Only; FEHL/PDL). The health insurer states that to be eligible for health insurance you must work full time and be actively at work. This may change with the healthcare reform so stay tuned.

Q: Do FMLA and CFRA run concurrently in cases for pregnancy?
A: Yes they do, and if you are disabled from pregnancy and you are in CA you also have FEHA, which if combined with FMLA and CFRA can get you greater time off.

Q: Does the company need to retro FMLA when a manager did not tell an employee he/she may be eligible for FMLA?
A: This is a legal question, so we cannot respond. Contact a labor attorney, you may have a case.

Q: What does capitation mean in provider excess loss?
A: Capitation is where an HMO pays a group of providers a defined amount of money to provide healthcare. If the money they collect is not enough due to a catastrophic patient, then the group will hopefully have in place a provider excess loss insurance policy (AKA Provider Stop Loss, Managed Care Excess and Capitated Stop loss, or Stop Loss Reinsurance). The policy allows the group to submit any claims they have usually after $15K or $20K is paid by the group for reimbursement.

Q: What happens when my employer denies my FMLA in California?
A: He/she is in big trouble. Report him/her to the department of labor and call a labor law attorney. The employer and any manager or supervisor, who is involved, is liable.

Q: What the difference between Standard vs Nonstandard Malpractice Insurance?
A: Standard insurance companies provide insurance for a certain risk profile: minimal claims, no medical board issues, and typical practice patterns. These insurers charge the least for coverage. The standard insurers have their rates filed with the department of insurance and they cannot charge more or less than those rates. If a doctor does not fit the standard insurers underwriting requirements, then they are rejected in the standard market since the insurers cannot charge more than their filed rates.

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Example: Dr. A is a general surgeon and a doctor who meets the standard underwriting. He would be charged $45K a year for his premium. However, Dr. A has lots of claims thus the standard insurer calculates that it should charge him $80K a year. But the standard insurer cannot charge $80K since the most it can charge is $45K, because these are the rates it has filed with the department of insurance. Thus it cannot accept Dr. A since he is a non standard risk. Now the non standard malpractice insurer does not want to be limited to filed rates so it does not file and does not have the oversight of the insurance department. It charges Dr. A $80K to insure him. The non standard market is the place for doctors, who cannot be accepted by the standard market. Insurance brokers need to work to get all their clients into the standard medical malpractice insurers. While a doctor is stuck in the non standard market, insurance brokers should shop insurers every year to find them the best deal possible.

Q: How does stop loss insurance work and best practices?
A: One needs to analyze your past shock loss claims. If you have a group that has a 1000 or more claims, your experience should be somewhat predictable. Use this to set your specific level. Also, see if you can share the stop loss premium (aggregating specific or retro) with the stop loss carrier.

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