Health Insurance Events/Documents

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Insurance Industry Forms - Health Insurance

A loss of coverage notice, an insurance experience letter, a reservation of rights letter, an eligibility notice after an out-of-state address change, and an insurance endorsement are documents that healthcare insurance providers can use to update their clients on activities associated with their health insurance. However, not all of these documents are typically sent out by insurers proactively. For example, an insurance experience letter is only sent out when a policyholder requests for it, and the eligibility notice is sent out after a person updates his or her information in the health insurance marketplace portal. We still included them in the list because they involve changes in the policyholder's account and the document sent to the policyholder includes the change of information.

INVOLUNTARY LOSS OF COVERAGE

  • What it is: A Loss of Coverage notice is a letter sent by the insurance provider or the former employer to the individual policyholder informing them of the loss of coverage.
  • What triggers it: This notice is sent out when the individual policyholder lost the coverage but didn't cancel the plan themselves. A very common example of this is when an individual leaves their employer, either voluntarily or involuntarily, and lose access to their employer-sponsored plan as a result. Another example is when the healthcare insurance provider exits the market before the open enrollment period. For other reasons of involuntary loss of coverage, please visit this page.
  • What happens after it: This document will serve as a proof of loss of coverage that will allow the individual to qualify to enroll or get a plan outside of the open enrollment period. The application for new insurance coverage should be submitted within 60 days from when the previous coverage ended.


INSURANCE EXPERIENCE LETTER/INSURANCE CLAIMS HISTORY LETTER

  • What it is: An Insurance Experience Letter, also known as Letter of Experience for Insurance or Insurance Claims History Letter, is a formal document written by an insurance provider about the record of the policyholder with them.
  • What triggers it: Policyholders can call their agency to request for an insurance experience letter. The insured uses this document to verify their existing insurance information or as proof that they are insured.
  • What happens after it: Although an Insurance Experience Letter is not sent out unless requested, insurance providers can proactively send this to policyholders when there are changes in the account as this document contains information about the plan, such as the name of the policyholder, effective date of the insurance, policy number, claims made against the plan, claims paid, and details of such claims including how much was paid.


Reservation of rights letter

  • What it is: A reservation of rights notice is a document informing the policyholder that their claim might not be covered by the policy.
  • What triggers it: This letter is sent to inform the policyholder that further investigation is needed to approve or deny the claim. This is done when the insurer did not receive enough information about the claim filed; for example, insufficient information as to what happened, who was responsible, and other important details. Conducting an investigation to either approve or deny the claim and informing the policyholder of such action is the reservation of rights of the insurance company; and, thus, not sending the letter means they are waiving their rights.
  • What happens after it: This document can be used to update the policyholder about their health insurance plan because it informs them that a claim has been made. A reservation of rights letter contains information about a claim filed, including the policy in which the claim was made against and the part of the claim that possibly might not be covered. Some insurer may provide information on what aspects of the claim they are investigating. In case the claim filed is unauthorized, then the policyholder can be informed and thus report the case.


ELIGIBILITY NOTICE AFTER AN OUT-OF-STATE ADDRESS CHANGE

  • What it is: An eligibility notice is a document that explains to an individual what plans he/she qualifies for.
  • What triggers it: Address change happens when a policyholder moves to a new address and updates their information with their insurance provider. When a person moves within the same state, his coverage and savings option won't probably change, but the address has to be updated either by calling the insurance provider or logging into the provider's website and entering the new information. However, when moving out of state, the policyholder might not be able to keep their plan, so it is very important to report the address change, either by talking to a representative or updating the information on the provider's client portal or website. This is to ensure that the individual won't pay for coverage that doesn't apply in that address and get a new plan.
  • What happens after it: Typically, insurance providers don't send address change notice to policyholders. However, an insurance company can send an eligibility notice to the policyholder who just has their address changed, informing them if they qualify for the special enrollment period and what policies do they qualify for. Sending an eligibility notice after an address change informs the policyholder of the changes in the account and report the action if unauthorized.

INSURANCE ENDORSEMENT DOCUMENT

  • What it is: An insurance endorsement document, also referred to as riders, is a legally binding addition or amendment of an existing insurance contract. This changes the scope or terms of the original plan.
  • What triggers it: This document may be issued by the insurance provider at the time of the purchase of the plan, mid-term, or at renewal. Insurance providers create endorsements to offer more options to the insurer, such as increasing coverage limit or adding coverage; however, endorsements can also be used to restrict or limit coverage.
  • What happens after it: This can be sent to inform the policyholder of the changes in their account. For example, after an address change, an endorsement can replace the previous version of a policy contract that has the policyholder's old address, which is no longer valid.
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