Medical Stop Loss Insurance
Self-funded employee medical plans can help companies manage costs and reduce regulatory complexities – but they also increase financial risk.
Stop-loss insurance is an essential way to reduce that risk. AIG works closely with businesses to design programs that provide more control over plan funds and provide reimbursement in the event of excessive claims.
Benefits of Medical Stop Loss
With AIG, you may get additional healthcare savings through discounts on administrative services, cost management tools andnetwork access fees. You’ll have more control over your health plan reserves, enabling maximized interest income.
Subject to applicable law, you can tailor your coverage based on what your employees need and what you can afford, knowing that specific and aggregate stop-loss coverage can mitigate exposure to individual catastrophic claims or an abnormal number of claims over a plan year.
The Company will not reimburse the policyholder for expenses that:
- Have been reimbursed by another company or reinsurance company or are reimbursable under a government or privately supported medical research program.
- Are not incurred and paid during the Benefit Period.
- Have been excluded, or adjusted, under the terms of the Adjusted Specific Deductible Endorsement or the Aggregating Specific Corridor Agreement.
- Are for any injury or illness arising out of, or in the course of, any employment for wage or profit for which the covered participant is entitled to benefits under any Workers’ Compensation or occupational disease policy whether or not such policy is actually in force.
- Are for the cost of administration of claims, investigation expenses, payments or other services provided by the TPA, consulting fees, or any other fees or expenses incurred by the plan that are not defined as plan benefits.
- Are recoverable from any person responsible for causing the injury or sickness which gave rise to the benefit provided under the plan or from any other company or other organization providing benefits or services for the injury or sickness which gave rise to the benefits under the plan; if a covered participant is eligible for
- Medicare, as their primary payor, benefits under this policy will be reduced by the amount of any Medicare benefits received by the covered participant so that total reimbursement will not exceed 100% of the covered participant’s actual eligible expenses.
- Are payments for treatment or services which are considered experimental or investigational as defined in the plan or as defined in the Experimental/ Investigational & Medical Necessity Endorsement if not defined in the plan.
- Are any amount in excess of the amount payable under the plan.
- Are caused by or result from war, declared or undeclared, invasion, acts of foreign enemies, hostilities, civil war, rebellion, insurrection, military or usurped power, or martial law or confiscation by order of any government or public authority.
- Are for legal fees or expenses related to litigation with claimants under the policyholder’s plan, including, but not limited to,
- compensatory, punitive, exemplary or extra contractual damages, fines or statutory penalties.
- Are payments for treatment or services which are not medically necessary as defined in the plan or as defined in the
- Experimental/Investigational & Medical Necessity Endorsement if not defined in the Plan.
- Result from dental, vision, prescription drugs, hearing care or weekly income unless specifically included in the Schedule of Coverages.
- Are incurred by any affiliate or subsidiary company of the policyholder not included in the policy at issue, unless specifically added by rider, letter of agreement, or endorsement.
- Are paid in accordance with amendments, endorsements, letters of agreement to the plan prior to the date such documents are approved by the company in writing.
- Are incurred by the policyholder for non-compliance with any legal statute or regulation.
- Are in excess of the usual and customary charges, as referenced in the plan, for the service or supply in the locality where such service or supply is received regardless of any preferred provider contract that exists with the provider of such service or supply.