What Document Describes an Insured’s Medical History?
Discover how insurers access your medical history for coverage, the key documents involved, and how your privacy is protected.
Understanding an individual’s medical history is a fundamental aspect of the insurance industry. Insurers rely on this information to accurately assess risk, determine eligibility for coverage, and set appropriate premiums. This process, known as underwriting, ensures that policies are priced fairly based on the potential health-related costs an insured might incur.
Attending Physician Statement
A primary document insurers use to understand an individual’s medical history is the Attending Physician Statement (APS). This detailed medical report is prepared by a patient’s healthcare provider. Insurers frequently request an APS during the application process for life, disability, critical illness, or long-term care insurance.
The information in an APS generally includes diagnoses, symptoms, condition severity, and treatment plans. It may also provide details on prescriptions, medical test results, and a physician’s opinion on how a condition impacts an individual’s ability to work or perform daily activities. An APS offers a summary that supports insurer decisions on coverage or claims.
Sources of Medical Information for Insurers
Beyond the Attending Physician Statement, insurers gather medical history from several other sources. Direct medical records from hospitals or clinics provide comprehensive details, offering in-depth information about past treatments, hospitalizations, and specialist consultations.
Paramedical exams are another common method, especially for life insurance applications. Conducted by trained medical professionals, these exams involve a review of medical history, vital sign measurements, and the collection of blood and urine samples. These samples are then tested for various health indicators and risk factors.
Pharmacy prescription histories offer insights into an individual’s health conditions and ongoing treatments. Prescription data, with applicant authorization, can be sold to insurers, allowing them to infer medical conditions and assess potential costs. Additionally, the Medical Information Bureau (MIB) serves as a central database for coded health information shared among member insurers. The MIB’s purpose is to detect fraud and ensure accuracy by alerting insurers to significant medical conditions reported by previous applications. This coded data acts as an alert system, prompting insurers to investigate further.
Protecting Medical Information
Protecting an individual’s medical information is governed by federal laws like the Health Insurance Portability and Accountability Act (HIPAA). HIPAA establishes national standards for safeguarding Protected Health Information (PHI). This law requires health plans, healthcare providers, and their business associates to implement safeguards ensuring the confidentiality and integrity of health data.
Under HIPAA, insurers cannot access an individual’s medical records without explicit written consent. This consent specifies which records can be accessed and for what purpose, ensuring only pertinent information is shared. Individuals also retain the right to access their own medical records, request corrections, and receive a notice. These protections balance the insurer’s need for information with the individual’s right to privacy.