In this article we will explore the reasons that motivate employers to get group health insurance for employees and we will look at the advantages and disadvantages from both points of view.
Group Health Insurance VS Individual Private Health Insurance
Probably the most significant distinguishing characteristic of group insurance is the substitution of group underwriting for individual underwriting. In group cases, no individual evidence of insurability is usually required, and benefit levels can be substantial, with few, if any, important limitations.
Group underwriting normally is not concerned with the health or other insurability aspects of any particular individual. Instead, it aims to obtain a group of individual lives or, what is even more important, an aggregation of such groups of lives that will yield a predictable rate of mortality or morbidity. If a sufficient number of groups of lives is obtained, and if these groups are reasonably homogeneous in nature, then the mortality or morbidity rate will be predictable. The point is that the group becomes the unit of underwriting, and insurance principles may be applied to it just as in the case of the individual. To assure that the groups obtained will be reasonably homogeneous, the underwriting process in group insurance aims to control adverse selection by individuals within a group.
In underwriting group insurance, then, certain important features should be present that either are inherent in the nature of the group itself or may be applied in a positive way to avoid serious adverse selection such as:
Insurance Incidental to the Group: The insurance should be incidental to the group; that is, the members of the group should have come together for some purpose other than to obtain insurance. For example, the group insurance furnished to the employees of a given employer must not be the feature that motivates the formation and existence of the group.
Flow of Persons through the Group: There should be a steady flow of persons through the group; that is, there must be an influx of new young lives into the group and an out flow from the group of the older and impaired lives. With groups of actively working employees, it may be assumed that they are in average health.
Automatic Determination of Benefits: Group insurance underwriting commonly requires an automatic basis for determining the amount of benefits on individual lives, which is beyond the control of the employer or employees. If the amount of benefits taken were completely optional, it would be possible to select against the insurer because those in poor health would tend to insure heavily and the healthy ones might tend to elect minimum coverage.
As the group mechanism has evolved, however, insurers have responded to demands from the marketplace, particularly large employers, for more flexibility in the selection of benefits. This flexibility typically is expressed in optional amounts of life and health insurance in excess of basic coverage provided by the employer and in more health care financing choices. Also, increasingly popular cafeteria plans allow participating employees to select among an array of benefits using a predetermined allowance of employer funds. Individuals select, subject to certain basic coverage's being required, a combination of benefits that best meet his or her individual needs.
Minimum Participation by the Group: Another underwriting control is the requirement that substantially all eligible persons in a given group be covered by insurance. In plans in which the employee pays a portion of the premium (contributory), generally at least 75 percent of the eligible employees must join the plan if coverage is to be effective. In the case of noncontributory plans, 100 percent participation is required. By covering a large proportion of a given group, the insurance company gains a safeguard against an undue proportion of substandard lives. In cases in which employees refuse the insurance for religious or other reasons that do not involve any elements of selection, this rule is relaxed.
Third Party Sharing of Cost: A portion of the cost of a group plan ideally should be borne by the employer or some third party, such as a labor union or trade association. The noncontributory employer-
Contributory plans usually are less costly to the employer. Hence, with employee contributions, the employer is likely to arrange for more adequate protection for the employees. It can also be argued that, if the employee contributes toward his or her insurance, he or she will be more impressed with its value and will appreciate it more. On the other hand, the contributory plan has a number of disadvantages. Its operation is more complicated, and this at times, increases administrative cost considerably.
Each employee must consent to contribute toward his or her insurance, and as stated before, a minimum percentage of the eligible group must consent to enter the arrangement. New employees entering the business must be informed of their insurance privilege. If the plan is contributory, employees may not be entitled to the insurance until they have been with the company for a period of time. If they do not agree to be covered by the plan within a period of 31 days, they may be required to provide satisfactory evidence of insurability to become eligible. Some noncontributory plans also have these probationary periods.
Efficient Administrative Organization: A single administrative organization should be able and willing to act on behalf of the insured group. In the usual case, this is the employer. In the case of a contributory plan, there must be a reasonably simple method, such as payroll deduction, by which the master policy owner can collect premiums. An automatic method is desirable for both an administrative and underwriting perspective. A number of miscellaneous controls of underwriting significance are typically used in group insurance plans, but the preceding discussion permits an appreciation of the group underwriting underwriting theory. The discussion applies to groups with a large number of employees.
A majority of the groups, however, are not large. The group size is a significant factor in the underwriting process. In smaller plans, more restrictive underwriting practices relating to adverse section are used. These may include less liberal contract provisions, simple health status questions, and in some cases, detailed individual underwriting of group members.
Group Policy: A second characteristic of group insurance is the use of a group policy (contract) held by the owner as group policyholder and booklet-
Lower Cost: A third feature of group insurance is that it is usually lower-
The marketing system relieves the agent or broker of many duties, responsibilities, and expenses normally associated with selling or servicing of individual insurance. Because of the large premiums involved in many group insurance cases, the commission rates are considerably lower than for individual contracts and are usually graded downward as the premium increases. Some large group insurance buyer's deal directly with insurance companies and commissions are eliminated. In these cases, however, fees frequently are paid to the consultants involved. The nature of the administrative procedures permits simplified accounting techniques. The mechanics of premium collection are less involved, and experience refund procedures much simplified because there id only one party with whom to deal with such as the group policy owner.
Of course, the issuance of a large number of individual contracts is avoided and, because of the nature of group selection, the cost of medical examinations and inspection reports is minimized. Also, regulatory filings and other requirements are minimized. In the early days of group insurance, administration was simple. That is no longer true. Even with group term life insurance, for which there is no cash value, the push for accelerated death benefits, assignment to viatical companies, and estate or business planning record keeping means that the administration of coverage may be as complex as with an individual policy.
Flexibility: in contrast to individual contracts that must be taken as written, the larger employer usually has options in the design and preparation of the group insurance contract. Although the contracts follow a pattern and include certain standard provisions, there is considerably more flexibility here than in the case of individual contracts. The degree of flexibility permitted is, of course, a function of the size of the group involved. The group insurance program usually is an integral part of an employee benefit program and, in most cases, the contract can be molded to meet the objectives of the contract owner, as long as the request do not entail complicated administrative procedures, open the way to possibly serious adverse selection, or violate legal requirements.
Experience Rating: Another special feature of group insurance is that premiums often are subject to experience rating. The experience of the individual group may have an important bearing on dividends or premium-
Some insurers experience rate based on the class or type of industry, or even based on the type of contract. For small groups, most insurance companies' use pooled rates under which a uniform rate is applied to all such groups, although it is becoming more common to apply separate pooled rates for groups with significantly better or worse experience than that of the total class. The point at which a group is large enough to be eligible for experience rating varies from company to company, based on that insurer's book of business and experience. The size and frequency of medical claims vary considerably across countries and among geographic regions within a country and must be considered in determining a group insurance rate. The composition (age, sex, and income level) of a group will also affect the experience of the group and, similarly, will be an important underwriting consideration.
Advantages and Limitations of the Group Mechanism.
Advantages: The group insurance mechanism has proved to be a remarkably effective solution to the need for employee benefits for a number of reasons. The utilization of mass-
Another significant factor, and one of the more cogent motivations for the rapid development of group insurance, has been the continuing governmental role in the security benefits area. Within the United States, Old-
Disadvantages: From the viewpoint of the employee, group insurance has one great limitation-
Retiree group health insurance often is provided as a supplement to Medicare. Another problem of potential significance involves individuals who may be lulled into complacency by having large amounts of group insurance during their working years. Many of these persons fail to recognize the need for, or are unwilling to face the cost of, individual insurance. Perhaps of even greater significance is the fact that the flexibility of the group approach is limited to the design of the master policy and does not extend to the individual covered employees. Furthermore, group plans typically fail to provide the mechanism for any analysis of the financial needs of the individual which is a service that is normally furnished by the agent or other advisor. Many agents, however, discuss group insurance coverage with individuals as a foundation for discussing the need for additional amounts of individual life and health insurance...