Week 12: Private Insurance
Insurance was briefly discussed when we examined dental insurance during week 7. This week you will review some insurance terms and explore new concepts about private insurance including employment opportunities in this industry!
Insurance Review
What do you remember about insurance from the first half of our course?
Private Insurance vs. OHIP
Not every Canadian has access to private health insurance as they do provincial health insurance like OHIP. Rather than being administered through the government, private insurance is run by many different for-profit businesses. Each plan (policy) will have different coverage amounts and provisions.
Canadians may receive private insurance through their employer, school, spouse, or parents, or may pay a monthly fee to self-insure.
Did you know that you have insurance as a full-time Conestoga student? Visit the Conestoga website to review your coverage details.
Types of Coverage
The categories of private insurance coverage include the following:
- Paramedical: includes coverage for health care providers including registered massage therapists, chiropractors, osteopaths, physiotherapists, etc.
- Vision: includes coverage for eye exams, glasses, lenses, etc.
- Drugs: includes prescription medications
- Dental: as covered in week 7, this includes various dental services
- Hospital: non-OHIP fees including private room upgrades
- Travel: coverage for health expenses once outside of Canada
- Disability: coverage for lost wages due to a disability
- Other (accidental death & dismemberment, critical illness, life insurance): financial payouts in the event of significant loss
All policies are different and some will not include all categories listed above.
HOA Insurance Career Opportunities
With the knowledge and skills you have gained from this program, you may consider career paths related to health within the insurance industry.
Some examples include underwriting, claim adjudication, customer service representative, admin, and sales-marketing representative. Browse the career pages of insurance companies and review the job descriptions. Many will note that medical terminology and healthcare education are considered assets. Let’s review two opportunities:
Underwriting
What does an underwriter do?
Underwriters assess risk. Consider the risks we take that negatively impact our health. An underwriter will review medical documentation including physical exam reports, attending physician statements, and client applications and compare them against mortality data. They will then determine how much a person should pay to have insurance coverage with their company.
If a client misrepresents themselves on an application, such as telling a lie or providing inaccurate medical information, the insurance company can deny a claim and/or remove them from coverage.
Underwriting can be applied in a group setting (assess the risk for a group of employees). Or can be assessed for an individual (1 person).
Claim Adjudication
What does a claim adjudicator do?
A claim adjudicator reviews private insurance claim submissions and determines how much (if at all) a client or clinic should be paid.
They must first review the insurance policy and familiarize themselves with the coverage details and provisions. They would then verify that the client is covered under the policy and is eligible for this category and service. If missing or incorrect information is listed, they would decline the claim.
If the client is eligible for coverage, the adjudicator would review who should receive the money and issue payment. If the client has paid for the service and is submitting the claim, payment would be made to the member. If the clinic that performed the service submitted the claim on behalf of the client, the adjudicator would release payment to the clinic directly.
Coordination of Benefits
Rules of Coordination of Benefits
If a client has coverage under more than 1 private insurance plan as the plan member
- Submit the claim FIRST under the plan in which they are a full-time employee
- If they are full-time or part-time at both, submit FIRST under the plan in which the client has been employed the longest
If a client has coverage under more than 1 private insurance plan (1 as the plan member and 1 as a dependent on a spouse/parent plan)
- Submit the claim FIRST under the plan in which they are the plan member
- Submit the claim SECOND under the plan in which they are a dependent
Coordination of Benefits for Children
If a client is covered under both their parents’ plans, apply the following rules:
- The Birthday Rule
- Submit the claim FIRST under the plan of the parent whose birthday (month/day) occurs closest to January 1st. Submit any remaining amount SECOND under the other parent’s plan.
- The Alphabet Rule
- If both parents have the same birthday, submit the claim FIRST under the parent whose first name begins with the earlier letter in the alphabet. Submit any remaining amount SECOND under the other parent’s plan.
If a client is a child of divorce, apply the following rules:
- Custody
- Submit the claim FIRST under the plan of the parent with primary custody
- Submit the claim SECOND under the plan of the spouse of the parent with primary custody
- Submit the claim THIRD under the plan of the parent without primary custody
- Submit the claim FOURTH under the plan of the spouse of the parent without primary custody
Let’s Practice!
In class, we will be practicing manual submissions of private insurance claim forms and coordination of benefits examples.
