HSA Health Conditions /
Underwriting Factors |
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Qualification For Individual And/Or Family Health Insurance
(Fortis Insurance Company Underwriting Guidelines 11/2004) |
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| Part 1 - Eligibility Review |
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| | A “Yes” Answer To Any Of The Following Questions Disqualifies The Applicant: |
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| 1. | Does any person to be insured have or has the person ever had any of the ineligible medical conditions listed in Part 2 below? |
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| 2. | Is any person to be insured over the acceptable height/weight limits listed below? |
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| | Unisex Height/Weight Maximum Table
(applicants above the weight listed for thier height will be declined) | | Height | Maximum
Weight (lbs.) | Height | Maximum
Weight (lbs.) | | 4’10” | 190 | 5’10” | 277 | | 4’11” | 197 | 5’11” | 285 | | 5’0” | 203 | 6’0” | 293 | | 5’1" | 210 | 6’1” | 301 | | 5’2” | 217 | 6’2” | 310 | | 5’3” | 224 | 6’3” | 318 | | 5’4” | 231 | 6’4” | 327 | | 5’5” | 239 | 6’5” | 336 | | 5’6” | 246 | 6’6” | 345 | | 5’7” | 254 | 6’7” | 354 | | 5’8” | 261 | 6’8” | 363 | | 5’9” | 269 | | |
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| 3. | Is any person to be insured employed in an ineligible occupation listed below? |
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| Top | | Ineligible Occupations List - | - Applicants recently laid off, temporarily unemployed, between jobs or on medical disability
- Air traffic controllers
- Armed Forces personnel
- Asbestos/toxic chemical workers
- Divers (professional skin or scuba)
- Explosive workers
- Fishermen/crew
- Off-shore oil workers
- Oil and natural gas workers, including off-shore operations
- Professional auto racers
- Professional athletes including but not limited to: ballet, baseball, basketball, football, wrestling
- Professional crop dusters
- Structural steel workers
- Stunt flyers
- Underground miners
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| 4. | Is the applicant, spouse or any of their dependents, regardless if applying for coverage, currently pregnant or an expectant parent? (If yes, coverage cannot be issued on a pregnant female, or the father of an unborn child. Coverage for the pregnant mother or the father of the unborn child is not available until the pregnancy has ended. To be eligible to apply for coverage, the baby must have had a well baby exam at least 2 weeks after medical discharge.) |
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| 5. | Does any person to be insured have a pending doctor appointment (other than routine) or has diagnostic testing, treatment or surgery been recommended or scheduled that’s not completed? (Ineligible applicants are those with non-routine appointments, diagnostic testing, treatment or surgery. These applicants should postpone applying until after the appointment, treatment or surgery is complete and the results and diagnosis are known.) |
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| 6. | Is any person to be insured not a U.S. citizen, or an immigrant here on visa status or has any person to be insured been in the U.S. less than one year? |
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| 7. | Has any applicant age 55 or older not had a physical within the last 5 years? |
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| 8. | Does any person to be insured have plans for extended travel abroad? (Those contemplating extended travel (3 months or more) are not eligible for individual medical insurance coverage. This includes students who travel abroad or study overseas.) |
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| 9. | Will any person to be insured become eligible for any other form of medical insurance in the next six months? |
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Part 2 - Ineligible Medical Conditions |
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| A B C D E F G H I K L M N O P Q R S T U V W |
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| A | Addison’s disease
Adult respiratory distress syndrome
(ARDS) with severe respiratoryimpairment
AIDS
Alzheimer’s disease
Amphetamine usage
Amyotrophic lateral sclerosis (ALS)
Aneurysm
Angina (unstable, variant, prinzmetal,vasospastic)
Ankylosing spondylitis
Anorexia nervosa - < 5 years since disease controlled = Decline
> 5 years since disease controlled = Individual Consideration
Aortic arch arteritis
Aortic insufficiency
Aortic stenosis
Aortitis
Aplastic anemia
Aregenerative anemia
Arterial embolism (clot)
Arterial occlusion
Arteriosclerosis obliterans (ASO)
Arteriovenous malformation
Arteritis
Ataxia telangiectasia
Atherosclerosis obliterans
Atherosclerosis thrombotic disease
Atrial fibrillation – chronic
Autism |
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| B | Banti’s syndrome (spleen disorder)
Berger’s disease
Bipolar disorders
Bladder extrophy (congenital malformation of the bladder wall)
- Asymptomatic – permanent rider
- Symptomatic – decline |
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| C | Cancer (with lymph node involvement or metastasis)
Cardiac decompensation
Cardiac Defibrillator (implantable)
Cardiomyopathy
Cerebral palsy
Charcot’s syndrome
Charcot-Marie Tooth disease (if present)
Chediak Higaski syndrome
Christmas disease
Chronic Granulomatous disease
Chronic obstructive pulmonary disease (COPD)
Cirrhosis of the liver
Coarctation of the aorta
Cocaine abuse
Common Variable Immunodeficiency
Congenital lymphedema
Congestive heart failure (CHF)
Cor pulmonale
Coronary artery bypass surgery
Coronary artery disease (CAD)
Coronary heart disease (CHD)
Crohn’s disease
Curvature of the spine (with pulmonary, cardiac or spinal cord involvement)
Cushing syndrome (caused by bilateral adrenal hyperplasia or administration of steroids to treat another disorder)
Cystic fibrosis
Cystic medical necrosis |
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| D | Dejerine type sclerosis
Dementia
Depressant addiction
Depression – major (if hospitalization required)
Di George syndrome
Diabetes mellitus
Down Syndrome |
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| E | Ebstein’s malformation
Eisenmenger’s complex
Eosinophilic granuloma
Eosinophilic granuloma of bone
Esophageal varices (varicose veins in the esophagus)
Ehlers-Danlos syndrome |
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| F | Fabry disease
Factor VIII or IX deficiency (clotting disorder)
Fragilitas ossium |
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| G | Gargoylism
Gastric bypass/stapling
Gaucher’s disease
Gender identity disorder
Gilles de la Tourette’s syndrome
Glycogen storage disease |
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| H | Hand-Schuller-Christian disease
Heart-lung transplants
Heavy chain disease
Hemiplegia
Hemochromatosis
Hemophilia A or B
Histocytosis X
Hodgkin’s disease
Hydrocephalus
Hydronephrosis (bilateral)
Hypersplenism
Huntington’s chorea
Hypoplastic anemia |
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| I | IgG Subclass Deficiency
Ischemic heart disease |
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| K | Kahler’s disease
Kartagener’s syndrome
Kidney transplant |
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| L | Letterer-Siwe disease
Leukemia
Liver transplant
Lobstein’s disease
Lou Gehrig’s disease
Lymphoblastoma
Lymphomatoid Papulosis
Lymphoma |
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| M | Marchiafava-Micheli syndrome
Marfan’s syndrome
Marijuana usage (current or past history in conjunction with other drugs)
Mental retardation (severe, emotionally unstable, seizures or psychiatric impairments)
Mesenteric vascular disease
Milroy’s disease
Mitral insufficiency
Mitral stenosis
Mixed connective tissue disease
Mongolism
Mucopolysaccaridosis
Multiple myeloma
Multiple sclerosis
Muscular dystrophy
Myocardial infarction (MI)
Myocardial ischemia |
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| N | Narcotic use/addiction
Nephrocalcinosis
Nephrosclerosis
Neurofibromatosis
Niemann-Pick disease |
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| O | Osteitis fibrosa cystica disseminate
Osteitis fibrosa cystica generalisata
Osteogenesis imperfecta |
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| P | Pacemaker
Pancytopenia
Paralysis
Paranoid or other psychotic disorder
Paraplegia
Parkinson’s disease
Paroxysmal nocturnal hemoglobinuria
Percutaneous transluminal coronary angioplasty
Periarteritis nodosa
Peripheral occlusive arterial disease (POAD)
Peripheral vascular disease
Personality disorder
Pituitary dwarfism
Plasmacytoma
Pneumocystitis carinii pneumonia (PCP)
Polyarteritis
Polycystic kidney
Polycythemia vera
Polyglandular autoimmune disease
Porphyria (diagnosed less than 5 years prior to application)
Primary pulmonary hypertension
Primary sclerosing cholangitis
Pseudohemophilia
Psychedelics usage (LSD, PCP)
Psychiatric disorder – severe childhood and adolescence
(including conduct disorder & oppositional defiant disorder)
Pulmonary heart disease
Pulmonic insufficiency
Pulmonic stenosis
Pulseless disease |
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| Q | Quadraplegia |
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| R | Rhabdomyosarcoma |
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| S | Sarcoma
Schizo-affective disorders
Schizophrenia
Scleroderma (systemic)
Severe combined immunodeficiency
Sick sinus syndrome
Sickle cell anemia
Silent myocardial ischemia
Spurway’s disease
Stimulant usage (amphetamines, cocaine)
Stroke
Sturge-Weber syndrome
Suicide attempt
Syndrome X
Systemic lupus erythematosis |
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| T | Takaysu’s disease
Tetrology of fallot
Thalassemia major
Total anomalous pulmonary venous connection
Tourette’s syndrome
Transient ischemic attack (TIA)
Transplant (except corneal transplant)
Transposition of the great vessels
Transsexualism
Tricuspid atresia
Tricuspid stenosis
Trisomy 21 syndrome
Truncus arteriousus |
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| U | Ulcerative colitis |
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| V | Valve replacement
Vascular hemophilia
Ventricular arrhythmia
Von Hipple-Lindau syndrome
Von Willebrand’s disease |
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| W | Waldenstrom’s macroglobulinemia
Wegener’s granulomatosis
Wilson’s disease
Wiskott Aldrich syndrome |
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| | Part 3 - Non-Disqualifying Medical Conditions And Underwriting Factors Check List |
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| | Please review the following medical conditions and circle any that you or any person applying for coverage were diagnosed with, received treatment for, or consulted a physician for in the past 10 years. Presence of these conditions will not necessarily disqualify the applicant but may increase the rate charged or require a condition exclusionary rider. These conditions are examples of the medical category under which they are shown and do not necessarily include all the conditions related to that category. (Note: failure to disclose a material medical condition or other factor relevant to the insurer’s decision to accept the risk constitutes a fraud and can result in the policy being rescinded and claims not paid). |
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