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You are here:OPM Home > Insurance > FLTCIP > FAQ > Application Questions on Health
Application Questions on Health FAQ
| Here are the actual underwriting questions from the applications. This is not a complete application, however. If you want to read or download an application, visit www.ltcfeds.com. Or call 1-800-LTC-FEDS (1-800-582-3337) (TTY: 1-800-843-3557) and request an Information Kit with Application.
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Q. What health-related questions are on the abbreviated underwriting application if you apply for the 3 year or the 5 year benefit period?
A. Employees who are eligible to use the abbreviated underwriting application and who elect the 3 year or the 5 year benefit period have to answer 7 questions (see below). Spouses answer these 7 questions and then 2 additional ones also shown below:
- Do you currently reside in, or has a health professional advised you to enter, a nursing home or any type of assisted living facility?
- Are you currently receiving home health care services or attending adult day care?
- Do you currently require or receive human help or supervision with any of these activities?
- Bathing
- Dressing
- Eating
- Transferring yourself from bed to chair
- Toileting (getting to and using the toilet, completing hygiene-related functions after use)
- Continence (changing protective undergarments, managing ostomy bags and catheters, completing hygiene-related functions)
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NOTE -If the answer is YES to any of questions 1 - 3, the applicant will not be eligible for insurance, but will be offered a service package.
If the answer is NO to all of questions 1 - 3, the applicant continues with question 4.
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- Do you currently have, or have you been diagnosed with, or been treated for, any of the following conditions?
- Alzheimer's Disease, Organic Brain Syndrome, or Dementia
- Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig's Disease)
- Diabetes with amputation or ongoing complication affecting the kidney
- Multiple Sclerosis
- Muscular Dystrophy
- Parkinson's Disease
- Schizophrenia
- Stroke (CVA): multiple
- Stroke (CVA): within 5 years
- Stroke (CVA): with residual impairment (e.g., paralysis, weakness, gait disturbance, vision disturbance, mental impairment)
- Transient Ischemic Attack (TIA): multiple
- Transient Ischemic Attack (TIA): within 3 years
- Do you currently use any of the following medical devices, aids, or treatments?
- Hospital bed
- Motorized scooter
- Oxygen (except CPAP)
- Stair lift
- Dialysis
- Wheelchair
- Walker
- Do you currently require or receive human help or supervision with any of these activities because of mental retardation?
- Living independently
- Taking medications
- Shopping
- Preparing meals
- Using transportation
- Walking
- Making decisions about your money
- Have you been diagnosed with any mental or nervous disorder for which you have been hospitalized in the past 2 years or for which you have had 3 or more hospitalizations in the past 10 years?
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If the answer is YES to any of questions 4-7, the applicant will not be eligible for any of the standard insurance options. He/she will be offered a choice of alternative insurance (different benefits at higher premiums) or a service package.
Q. What additional health-related questions must SPOUSES of employees answer if they're applying with the abbreviated underwriting application?
A.
Spouses must answer the following two additional questions. Spouses who answered YES to either or both questions must explain and then sign an authorization to release medical records and give contact information for their primary physician. A registered nurse may call or visit them to get more information on their questions.
- Do you currently require or receive human help with any of these activities?
- Preparing meals
- Taking medications
- Shopping
- Making decisions about your money
- Using transportation
- Walking
- Do you use crutches and/or a multi-prong cane?
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Q. What additional health-related questions do those using the abbreviated underwriting application have to answer if they are requesting the UNLIMITED BENEFIT PERIOD?
A. In addition to the questions for the 3 year and 5 year benefit period, those using the abbreviated underwriting application must also answer the following questions if they are requesting the unlimited benefit period:
- Do you currently have, or have you been diagnosed with, or treated for, any of the following conditions?
- AIDS or AIDS-related complex
- HIV
- Cirrhosis
- Mental retardation
- Kidney failure
- Organ transplant (excluding cornea or bone marrow transplant)
- Spinal Cord Injury (e.g., paraplegia, quadriplegia)
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Note: If the answer to this question is YES, the applicant is not eligible for the unlimited benefit period. If the answer to this question is NO, the applicant continues with question 2 below.
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- Do you currently require or receive human help or supervision with any of these activities?
- Preparing meals
- Taking medications
- Shopping
- Making decisions about your money
- Using transportation
- Walking
- Do you currently use crutches and/or a multi-prong cane?
- Are you currently receiving disability income such as disability retirement annuity payments, VA disability compensation, worker's compensation, any Federal or state disability payments, or any other type of disability payment?
- Within the last 10 years, have you had, been diagnosed with or been treated for any of the following conditions?
- Stroke or Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Carotid Artery Disease
- Peripheral Vascular Disease
- Coronary Artery Disease (e.g., heart attack, angina), Heart Arrhythmia, Cardiomyopathy, Congestive Heart Failure, Aneurysm, Valvular Disease
- Diabetes (excluding gestational diabetes)
- Cancer (excluding basal cell cancer or squamous cell cancer of the skin)
- Chronic Kidney Disease (e.g., nephritis)
- Liver Disorder (e.g., hepatitis)
- Any Psychiatric Disorder (e.g., depression, bipolar disorder)
- Disorder of the Brain (e.g, tremor, seizure disorder, head injury, tumor, infection), Neuropathy, Syncope, Paralysis, any Chronic or Progressive Neurological disorder
- Chronic Lung Disease [e.g., COPD, emphysema, sarcoidosis, chronic bronchitis, asbestosis, asthma (excluding seasonal asthma), bronchiectasis, sleep apnea]
- Memory Loss
- Rheumatoid Arthritis, any other type of arthritis, Osteoporosis, Back Disorder, Scoliosis, Spinal Stenosis, Disc Disease
- Connective Tissue Disorder (e.g., scleroderma, systemic lupus, CREST syndrome)
- Muscle Disorder (e.g., fibromyalgia, polymyalgia rheumatica, chronic fatigue syndrome)
If the answer is "YES" to any of questions 2 - 5, the applicant explains in a chart:
- Diagnosis or Disorder
- Date of Onset
- Treatment Dates
- Contact Information for Treating Health Professional
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- Have you taken any prescription medications over the past 6 months?
If yes, the applicant explains in a chart:
- Medication
- Dosage
- Frequency
- Reason Prescribed
- Contact Information for Prescribing Health Professional
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Q. What health-related questions are in the full underwriting application?
A. There are three sets of questions about health in the full underwriting application. In addition, everyone completing the full underwriting application must sign a release of medical records, give contact information for their primary physician, and may have a telephone or in-person interview with a registered nurse.
Anyone using these full underwriting questions who is declined coverage will not be eligible for insurance, but will be offered a service package.
FIRST SET OF QUESTIONS
- Do you currently reside in, or has a health professional advised you to enter, a nursing home or any type of assisted living facility?
- Are you currently receiving home health care services or attending adult day care?
- Do you currently require or receive human help or supervision with any of these activities?
- Bathing
- Dressing
- Eating
- Transferring yourself from bed to chair
- Toileting (getting to and using the toilet, completing hygiene-related
functions after use)
- Continence (changing protective undergarments, managing ostomy bags
and catheters, completing hygiene-related functions)
- Do you currently have, or have you been diagnosed with, or been treated for, any of the following conditions?
- AIDS or AIDS related Complex
- Alzheimer's Disease, Organic Brain Syndrome, or Dementia
- Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig's Disease)
- Cancer within 2 years (excluding basal cell or squamous cell cancer of the skin)
- Cirrhosis
- Diabetes with amputation or complication affecting the kidney
- HIV
- Multiple Sclerosis
- Muscular Dystrophy
- Organ Transplant (excluding kidney, bone marrow or cornea transplants)
- Parkinson's Disease
- Schizophrenia
- Spinal Cord Injury (e.g. paraplegia, quadriplegia)
- Stroke (CVA): multiple
- Stroke (CVA): within 5 years
- Stroke (CVA): with residual impairment (e.g., paralysis, weakness, gait disturbance, vision disturbance, mental impairment)
- Transient Ischemic Attack (TIA): multiple
- Transient Ischemic Attack (TIA): within 3 years
- Do you currently use any of the following medical devices, aids, or treatments?
- Hospital bed
- Motorized scooter
- Oxygen (except CPAP)
- Stair lift
- Dialysis
- Wheelchair
- Walker
- Multi-prong cane
- Do you currently require or receive human help or supervision with any of these activities because of mental retardation?
- Living independently
- Taking medications
- Shopping
- Preparing meals
- Using transportation
- Walking
- Making decisions about your money
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If the answer is YES to any of questions 1 - 6, the applicant will not be eligible for insurance, but will be offered a service package.
SECOND SET OF QUESTIONS
- Do you currently have, or have you been diagnosed with, or treated for, any of the following conditions?
- Kidney transplant
- Kidney failure
- Mental retardation
- Paralysis of the extremities
- Do you currently require or receive human help or supervision with any of these activities?
- Preparing meals
- Taking medications
- Shopping
- Making decisions about your money
- Using transportation
- Walking
- Do you currently use crutches, cane, prosthetics, braces, or catheter?
- Are you currently receiving disability income such as disability retirement annuity payments, VA disability compensation, worker's compensation, any Federal or state disability payments, or any other type of disability payment?
- Within the last 10 years, have you had, been diagnosed with or been treated for any of the following conditions?
- Stroke or Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Carotid Artery Disease
- Peripheral Vascular Disease
- Coronary Artery Disease (e.g., heart attack, angina), Heart Arrhythmia, Cardiomyopathy, Congestive Heart Failure, Aneurysm, Valvular Disease
- Diabetes (excluding gestational diabetes)
- Cancer (excluding basal cell cancer or squamous cell cancer of the skin)
- Chronic Kidney Disease (e.g., nephritis), Incontinence, Prostate Disorder
- Liver Disorder (e.g., hepatitis), Ulcerative Colitis, Crohn's Disease
- Any Psychiatric Disorder (e.g., depression, bipolar disorder),
- Disorder of the Brain (e.g., tremor, seizure disorder, head injury, tumor, infection), Neuropathy, Syncope, Paralysis, any Chronic or Progressive Neurological Disorder
- Chronic Lung Disease [e.g, COPD, emphysema, sarcoidosis, chronic bronchitis, asbestosis, asthma (excluding seasonal asthma), bronchiectasis, sleep apnea]
- Memory Loss
- Rheumatoid Arthritis, any other type of Arthritis, Osteoporosis, Back Disorder, Scoliosis, Spinal Stenosis, Disc Disease
- Connective Tissue Disorder (e.g., scleroderma, systemic lupus, CREST Syndrome) Hemochromatosis
- Muscle Disorder (e.g., fibromyalgia, polymyalgia rheumatica, chronic fatigue syndrome)
- Fracture or Amputation
- High Blood Pressure
- Macular Degeneration, Glaucoma, Retinitis Pigmentosa, Meniere's
Disease
- Anemia, Polycythemia Vera, Thrombocytopenia, Hemochromatosis
- Alcoholism, Drug Dependency
If the answer is "YES" to any of questions 1 - 5, the applicant explains the following in a chart:
- Diagnosis or Disorder
- Date of Onset
- Treatment Dates
- Contact Information for Treating Health Professional
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- Have you taken any prescription medications over the past 6 months?
If yes, the applicant explains in a chart:
- Medication
- Dosage
- Frequency
- Reason Prescribed
- Contact Information for Prescribing Health Professional
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THIRD SET OF QUESTIONS
- Enter height and weight.
- Are you employed outside the home or engaged in any hobbies, social
activities or volunteer work? If yes, describe.
- Do you exercise regularly? If yes, describe.
- Have you used tobacco products (cigarettes, pipe, cigar, or chewing
tobacco) in the last 12 months? If yes, give type and frequency.
- Within the past 2 years, have you had a complete physical exam?
If yes, give Month, Year, and Physician's Name.
- Do you currently drink alcoholic beverages on a daily basis? If yes, enter number of drinks/day.
- Have you ever had an application for Life, Health, or Long Term Care
Insurance declined, postponed, modified or rated (offered insurance at a
higher premium rate than the standard premium rate)?
- Within the last 5 years, has a health professional recommended that you
should have any surgeries, tests, or procedures that you have not had
performed?
- Have you ever resided in a nursing home or any type of assisted living
facility?
- Have you ever attended adult day care or received home health care
services?
- Within the last 5 years (excluding childbirth without complications, the
common cold, flu or routine exams), have you ever been hospitalized,
consulted with, or received treatment from a health professional for a
disease or condition not previously stated?
If the answer is "YES" to any of questions 7 - 11, the applicant explains the following in a chart:
- Diagnosis or Disorder
- Date of Onset
- Treatment Dates
- Contact Information for Treating Health Professional
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