life-health-insurance

Life and Health Insurance

When to Use

• Explain life, health, disability, and LTC products and how individual vs group markets differ
• Walk through underwriting: risk classification, evidence of insurability, rate classes, appeals
• Clarify policy mechanics: face amount, beneficiaries, riders, exclusions, contestability
• Describe health plan design: networks, cost sharing, essential health benefits (ACA overview)
• Frame Medicare/Medicaid program context at overview level (not enrollment legal advice)
• Outline claims and benefits administration: life death claims, health claims, appeals, EOBs
• Compare distribution models (career agent, independent, broker, MGA, worksite)
• Interpret life/health metrics (lapse, persistency, loss ratio, MLR, benefit ratio)
• Outline state DOI, NAIC, ACA, and HIPAA privacy concepts—not legal or actuarial sign-off

When NOT to Use

• Property, casualty, GL, workers comp, or commercial auto lines → property-casualty-insurance
• Defined benefit pensions, 401(k), or retirement plan administration → pension-retirement-funds
• Loss development triangles, IBNR, mortality table construction, or appointed-actuary work → actuary
• Actuarial consulting SOW, due diligence engagement design, or opinion support governance → actuarial-consulting
• Legal interpretation of policy wording, coverage disputes, or regulatory enforcement → commercial-counsel
• Corporate FP&A, investor metrics, or non-insurance financial modeling → financial-analyst (if installed)
• SOC 2 / ISO control mapping without insurance operations context → compliance-engineer
• Executive strategy without insurance domain detail → business-consultant

Related skills

Need	Skill
P&C lines, FNOL, occurrence vs claims-made, cat reinsurance	property-casualty-insurance
Pricing, reserving, triangles, mortality/morbidity assumptions	actuary
Actuarial engagement scoping, SOW, due diligence, opinion support	actuarial-consulting
Pension and retirement plan design, funding, ERISA context	pension-retirement-funds
Contract review, policy disputes, regulatory interpretation	commercial-counsel
Financial statements, variance, non-insurance analytics	financial-analyst (if installed)
Technical control evidence, audit packages	compliance-engineer
IFRS 17 / insurance contract measurement (accounting)	ifrs
Anti-false-positive alert triage (fraud/claims analytics)	anti-false-positive-decision-making

Core Workflows

1. Engagement scoping

Before analysis:

1. Segment — Life vs health vs DI/LTC; individual vs group; admitted vs worksite
2. Product — Term, permanent, major medical, ASO, Medicare supplement, etc.
3. Decision — Quote, renewal, claim, benefit design, reinsurance placement, filing context
4. Jurisdiction — State(s), ACA market, Medicare/Medicaid program rules (overview)
5. Materiality — Face amount, member months, network, stop-loss, prior claims experience

See references/life_health_insurance_scope.md.

2. Life underwriting and products

1. Define insurable interest and purpose (protection, estate, business)
2. Collect application, labs, APS, financials, and MIB/inspection where applicable
3. Assign risk class (preferred, standard, substandard, table ratings)
4. Select product: term, whole, universal, variable (overview of tradeoffs)
5. Structure face amount, beneficiaries, and riders (Waiver, ADB, etc.)
6. Bind with contestability and suicide clause awareness; track in-force changes

See references/life_products_and_underwriting.md.

3. Health products and markets

1. Classify market: individual ACA, small/large group, self-funded ASO, government
2. Map benefit design: deductible, copay, coinsurance, OOP max, network tier
3. Note risk adjustment, pooling, and stop-loss for group blocks
4. Outline Medicare (Parts A–D, MA, Medigap) and Medicaid (overview only)
5. Align distribution and compensation (commission, PEPM, bonuses) to segment

See references/health_products_and_markets.md.

4. Disability, LTC, and riders

1. Distinguish short-term vs long-term disability definitions (own occ vs any occ overview)
2. Set elimination period, benefit period, and offsets (SSDI, workers comp)
3. Frame LTC triggers (ADLs, cognitive), benefit pool, inflation options
4. Inventory riders: waiver of premium, ADB, chronic illness, guaranteed insurability
5. Escalate contract interpretation to commercial-counsel

See references/disability_ltc_and_riders.md.

5. Claims and benefits administration

1. Life — death claim intake, proof of death, beneficiary verification, contestability check
2. Health — eligibility, authorization, claim adjudication, COB, appeals (internal/external overview)
3. Establish reserves directionally; detail with actuary
4. Manage fraud/SIU referrals and documentation standards
5. Close with file quality; feed experience to underwriting and product

See references/claims_benefits_and_administration.md.

6. Reinsurance, metrics, and regulation

1. Select life/health reinsurance structures (YRT, coinsurance, excess, stop-loss)
2. Compute lapse, persistency, loss ratio, MLR (health) with defined numerators
3. Separate attritional vs large claims in health narrative
4. Outline NAIC, state DOI, ACA reforms, and HIPAA privacy context (not legal advice)
5. Map distribution economics and MGA/program oversight

See references/reinsurance_metrics_and_regulatory.md.

Deliverable standards

Deliverable	Minimum content
Underwriting summary	Product, risk class, face/benefit, riders, open requirements
Coverage/benefit memo	Plan type, cost sharing, network, key exclusions, ACA/ERISA note if relevant
Claims status	Intake facts, eligibility/coverage position (preliminary), next steps
Reinsurance brief	Structure, retention, treaty type, data requirements
Metrics commentary	Period ratios, lapse/persistency, MLR drivers, actions

Always label preliminary coverage positions and regulatory comments as not legal or actuarial advice; escalate to qualified professionals for filings, sign-off, and disputes.

When to load references

• Scope and segments → references/life_health_insurance_scope.md
• Life products and underwriting → references/life_products_and_underwriting.md
• Health products and markets → references/health_products_and_markets.md
• Disability, LTC, riders → references/disability_ltc_and_riders.md
• Claims and administration → references/claims_benefits_and_administration.md
• Reinsurance, metrics, regulation → references/reinsurance_metrics_and_regulatory.md