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Senior Member
What is the name of your state? NC

My sister asked me to try to find out some info regarding her situation so here goes.

She was on a plan with Blue Cross Blue Shield (the name of the plan escapes me at the moment but I think it started with a G). Now from what I understand they don't usually base your plans on your claim history.

They notified her they were discontinuing the plan she was on and putting her on the Advantadge Plan. They were going to base the premiums and deductible on her claim history.

My question is, is that right? Can they base it on your claim history and change the way they are determining her payments based on it? I didn't think the Advantadge plan could do that.

Thanks in advance for any input.


I'm a Northern Girl
It would help to know if she is on an individual or a group plan.

However, in re-reading your question I see that they are discontinuing the plan she is on - they are not changing her plan because of her claims history. This is perfectly legal - they are allowed to discontinue plans and when they do so, generally they either offer a choice of plans to the insureds or move them to the plan that most closely matches the discontinued one.

I'm confused as to why you would think they could not base her premium on her claims history. On what else would they base it?
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Senior Member
Just her and her daughter are on the plan.

I realize it's legal to change the plan but she didn't think they could base it on your claim history because when you first apply for insurance I don't think they ask you for one on their ap do they? They may ask you for pre-existing conditions when filling out an ap but they don't ask for claim histories. They normally ask your age, birthday, where you live, pre-existing conditions, but not claim histories. At least when I filled out an ap they didn't, nor did they for her.

When she first signed up they didn't base it on anyone's claim history so she doesn't understand why they are doing it now. You see, she believes they are doing it because when she first signed up, her daughter was healthy. Now her daughter has just been diagnosed with a rare heriditary blood disease and the medical bills are piling up. She thinks they deliberately changed the payment thing and are now basing it on the fact that her daughter is sick. Using the claim history.

See what I'm getting at?

Anyway, a couple of other people told me they didn't think it was legal. That they've been doing alot of illegal stuff. So I'm kind of stumped.

Thanks for your input.



I would call and ask. The only thing that fits for me is what they may mean is that, rather than requiring all "old" policyholders to re-apply and answer health questions on applications.....they are issuing the new coverage based upon their evaluation of the medical conditions previously claimed for. I believe that this would be legal and seems to fit.


I'm a Northern Girl
I can't answer for individual coverage because my background is all with group. But with group coverage, while the initial premium may or may not be based on claims history, subsequent renewal premiums are. Depending on the size of the group and the state you live it, they may be based on just your own claims history or it may be based on the overall claims history of the "pool" (total of all groups of similar size and plan in the same general area or possibly state wide) but claims history is definitely factored in. It's only fair that groups with higher usage pay more than groups that seldom use the plan. I'm sure that individual policies have a similar basis.


Senior Member
Thank you so much for your responses. I see what you guys are saying. I'll pass the information along.:) Thanks again!

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