Hold Harmless Clauses

By Betsy Kelley
OMIC Underwriting Manager

[Digest, Spring 2000]

Contracts are a fact of life in most ophthalmic practices today. Providers sign contracts with health care plans, laser centers, finance companies, and other entities. Contracts outline each party’s responsibilities, compensation, and other terms. In many instances, contracts may include provisions that affect a provider’s professional liability exposure.

One provision frequently found in contracts is a hold harmless or indemnification clause whereby one party (usually the physician) agrees to contractually assume the liability exposure of the other party. Some indemnification clauses are quite broad, requiring that the physician hold the other party harmless for “any and all claims, suits, losses, or damages” arising from services rendered, without regard to which party was responsible for such activities or whether negligence was involved.

Other clauses are sufficiently narrow and require that the physician hold the other party harmless only for “claims, suits, losses, or damages arising solely from the physician’s negligence and not otherwise covered by insurance.” Indemnification clauses may be unilateral, meaning that only one party holds the other harmless, or they may be mutual, meaning that both parties agree to hold the other harmless for its own negligent actions.

OMIC provides limited contractual liability coverage within policy limits for indemnity and reasonable defense costs that insureds become legally obligated to pay pursuant to a hold harmless or indemnification agreement in a written contract between the insured and a hospital, health maintenance organization, preferred provider organization, or other managed care entity. This coverage is limited to indemnity and defense costs incurred solely from the performance of professional services provided by the insured and is solely for medical incidents otherwise covered under the policy. In certain circumstances, OMIC may, for an additional premium, extend contractual liability coverage by endorsement to other entities that are not engaged in the practice of medicine but may incur liability exposure as a result of their relationship with the insured.

OMIC’s policy excludes coverage for liability assumed under contract with other types of organizations if such liability would not exist in the absence of the contract. Therefore, OMIC generally recommends that indemnification clauses be removed from the contract, if possible. If the clause cannot be removed, OMIC recommends that it be replaced with a narrow, mutual hold harmless clause in which each party agrees to indemnify the other for losses arising solely from the party’s negligence.

Additional Insureds

A new trend is emerging in which organizations are no longer satisfied merely having the physician contractually agree to hold them harmless in the event of a claim. Instead, they are now adding clauses to their contracts requiring that the physician name them as an additional insured under the physician’s policy.

OMIC is generally able to name a third party as an additional insured only in situations where the entity is a management services organization (MSO) involved in administrative activities such as the purchase of equipment, billing, and other matters. Because they do not render medical services themselves, such organizations are frequently unable to purchase medical malpractice policies of their own.

With the exception of MSOs, OMIC will not name third parties, such as medical professional corporations or laser refractive centers, as additional insureds. Because these organizations render professional services themselves and are likely to be responsible to some extent for supervision and control of the physician’s activities, they are equipped to insure themselves or to purchase separate coverage for their liabilities. It is generally in the best interests of both parties to purchase their own insurance policy so separate limits apply. Otherwise, each party’s limits are reduced by any indemnity paid on behalf of the other party.

Other Provisions

Other contract provisions may specify the limits of liability that the physician must carry or may require that the physician provide evidence of insurance. Upon request, OMIC can issue a certificate of insurance to the organization, specifying the insured’s policy number, effective and expiration dates of coverage, and limits of liability. In addition, OMIC also will attempt to notify the certificate holder of any material changes in coverage, such as a change in limits or cancellation of coverage. Some contracts may require that the organization be provided with advance notice prior to cancellation or coverage changes. Although OMIC will do its best to provide ample notice to certificate holders, OMIC itself may not receive sufficient advance notice of requested changes to comply with such contract provisions. For this reason, such requirements should be removed from any contract.

As a service to its insureds, OMIC will review contract language*** as it relates to professional liability issues and provide advice regarding uninsured risks. To have OMIC review these contract provisions, contact the Risk Management Department at (800) 562-6642, ext. 603 or fax the specific clauses to (415) 771-7087.

*** NOTE: OMIC no longer reviews contract language. However, as a service available only to its insureds, OMIC will provide an analysis of indemnification agreements prepared by our Legal Counsel. Policyholders may share this analysis with their own attorney. To obtain this analysis, contact the Underwriting Department at (800) 562-6642, option  1 or via email at underwriting@omic.com, or the Risk Management Department at (800) 562-6642, option 4 or via email at riskmanagement@omic.com. 10/8/14.

Fraud and Abuse Coverage Options

By Kimberly Wittchow, JD

[Digest, Fall 2000]

For several years, the government has unwaveringly pursued physicians for alleged Medicare and Medicaid fraud and abuse. New emphases arise, from intra-practice consultations to dispensing services, but the outcomes seem to be the same. The government almost invariably finds the physician at fault in some way and assesses a reimbursement with little supporting explanation for remediation by the perplexed provider.

Many times when these issues arise, the physician will argue that “the carrier said I could bill this way.” The unfortunate truth is that, unless you have carrier guidance in writing, federal law enforcement agencies will refuse to listen to your supposed defense. Health care law attorney William A. Sarraille (see Lessons from the Fraud and Abuse Wars) advises writing to the carrier to confirm the advice given, specifying the date and time that you spoke to the carrier representative. Tell the carrier that you will act in reliance on the information provided unless it informs you in writing within 14 days that this information is not correct. Send the letter by certified mail (otherwise the carrier may deny receiving it) and keep a copy in a central binder so you can retrieve it if it is ever needed.

The federal government has at least proffered a little more general guidance. HCFA recently published its long-awaited voluntary compliance plan for individual and small physician practices, available online at www.dhhs.gov/oig/new.html.

Meanwhile, huge settlements still are being drafted and the government continues to bar doctors from billing the government for services rendered to elderly and poor patients. New studies show that in response doctors may be downcoding their billing to ensure that they are not targets of investigation. While most reports of such intentional downcoding are anecdotal, statistics show that physician coding for all levels of evaluation and management services declined in 1998 after a shift toward higher level codes between 1993 and 1997.

Expense, Fines & Penalties

To address this ongoing problem, OMIC now offers two types of insurance coverage for billing errors: Fraud & Abuse Legal Expense Reimbursement and Comprehensive Fraud & Abuse(including fines & penalties) coverage. Coverage under both policies pays for attorneys’ fees and associated expenses rendered in the defense of a covered proceeding.

The Legal Expense policy is available at three limits: $25,000, $50,000 and $100,000. The Comprehensive coverage is available at limits of $250,000, $500,000 and $1,000,000. In addition to attorneys’ fees, this coverage provides reimbursement for audit expenses and for fines or penalties assessed resulting from alleged billing errors. The actual overpayment by the payor, however, must be reimbursed to the payor by the insured.

Third Party Payors and Whistleblowers

In addition, OMIC has enhanced coverage under both forms to cover not only civil governmental proceedings alleging Medicare or Medicaid Fraud and Abuse, but also third party payor actions; in other words, claims made by commercial health insurance companies alleging billing errors.

The policy language also has been broadened to include qui tam, or whistleblower, actions. These are lawsuits filed by witnesses to the alleged wrongful practices brought on behalf of the government alleging Medicare or Medicaid fraud and abuse.

OMIC provides coverage at the basic Legal Expense limit of $25,000 per insured free of charge to its medical professional liability insureds ($50,000 effective January 1, 2011). Members of the American Academy of Ophthalmology may purchase these various billing error coverages for themselves, their employed optometrists, and business entities. Premiums vary depending on the coverage and limits selected. Discounted rates for groups may be available for practices comprising ten or more physicians.

For more information on OMIC’s Fraud & Abuse insurance, please contact Kim Wittchow at (800) 562-6642, ext. 653 or kwittchow@omic.com.

OMIC Fraud & Abuse Coverage

• Pays attorney’s fees and associated expenses
• Covers civil proceedings and third party payor or whistleblower actions.
• Optional comprehensive coverage for audits, fines & penalties.
• Limits of $25,000, $50,000 and $100,000 for Legal Expense coverage only.
• Limits of $250,000, $500,000 and $1,000,000 for Comprehensive Fraud & Abuse coverage.

Admitted v. Authorized Carrier Status

By Betsy Kelley
OMIC Underwriting Manager

[Digest, Winter 2001]

There are many factors to consider when selecting an insurance carrier. Price, coverage features, loss experience, and claims-handling philosophy are critical issues. So are a company’s integrity and financial stability. But what about its admitted status? Does it matter whether a carrier is admitted or authorized?

The Federal Risk Retention Act of 1986 created a new class of insurance company – the risk retention group (RRG) – and removed the regulatory impediments to obtaining licensure in each state of business that previously made it cost-prohibitive for carriers to offer coverage in a wide range of territories. Under the Act, a risk retention group is required to meet the financial and filing requirements in its selected state of domicile and to register with and file a business plan and other financial information in any other state in which it operates.

A major change created by the Act is the distinction between whether a carrier is registered or licensed to legally engage in the business of insurance in a particular state. A risk retention group need be licensed and admitted only in its state of domicile, where it is subject to the regulatory requirements and financial status reviews of that state’s insurance department. At the same time, the RRG can be registered in other states by annually filing in each of those states the necessary financial statements and other required information. Each state has control over registered companies and has the right under the Act to investigate the company’s financial status in the same manner it can investigate the financial status of any licensed insurance carrier operating within the state. Individual states retain authority over consumer protection issues and may investigate complaints against an authorized RRG just as they would against a licensed and admitted carrier. As an added protection, consumers may file complaints with the RRG’s state of domicile.

Unlike licensed and admitted carriers, risk retention groups do not participate in state guarantee funds and are, in fact, prevented from doing so by the Risk Retention Act. This does not mean that they are any more risky, however, and while a few RRGs did become insolvent during their first few years of formation, the vast majority of insurance company failures involve licensed and admitted carriers.

Furthermore, participation in a state fund does not guarantee that aggrieved policyholders will be made “financially whole.” Most funds do not adhere to the rigid actuarial standards that strong carriers such as OMIC follow in establishing reserves. When claims are covered through a guarantee fund, it is possible that payments will run only pennies on the dollar, and in some cases, may not be covered at all.

Instead of relying on a guarantee fund to provide security in the event of insolvency, a carrier should prevent insolvency by maintaining strong financial reserves, collecting actuarially sound premiums, purchasing reinsurance from a reputable source with a reasonable retention, properly underwriting applicants, and handling claims efficiently and effectively. If a carrier is following sound financial principles and operating legally, it should not matter whether it is admitted or authorized.

About OMIC
When OMIC was formed nearly 15 years ago, the founders believed a risk retention group would be the most cost-effective and beneficial form of organization in which to operate a nationwide insurance program for ophthalmologists. It would have been expensive and administratively cumbersome to become licensed and admitted in each of the 50 states in which OMIC does business. A risk retention group remains the most effective form of organization in which to operate and allows OMIC to keep premiums affordable.

OMIC is domiciled and licensed in the state of Vermont, a strong regulatory jurisdiction known for its excellent reputation and record and accredited by the National Association of Insurance Commissioners. OMIC’s independent financial ratings are superior to many licensed and admitted carriers. OMIC maintains an A- (Excellent) rating with A.M. Best. OMIC’s solid financial condition and strong ratings are due in part to loss experience that is 30% better than the expected industry standard for ophthalmology nationwide as well as to its comprehensive underwriting guidelines, particularly with respect to refractive surgery.

OMIC has three sources of funding for the payment of claims. First, OMIC collects premiums that are actuarially developed to cover anticipated losses. Then, OMIC purchases reinsurance from respected companies to help support large losses. Finally, OMIC maintains adequate surplus in the unlikely event that premium and reinsurance are insufficient to cover actual losses.

OMIC enjoys the support and exclusive sponsorship of the American Academy of Ophthalmology and is recognized as an approved carrier by 11 ophthalmic subspecialty and state societies. OMIC is a member of the Physician Insurers Association of America.

If you have questions about OMIC’s carrier status, please contact Betsy Kelley at (800) 562-6642, ext. 630 or bkelley@omic.com.

Hard Times Ahead for Doctors and Carriers

By James F. Holzer, JD
Mr. Holzer is OMIC’s President & CEO.

[Digest, Winter 2001]

The U.S. economy and stock market may be showing signs of renewed vibrancy this quarter, but malpractice insurance carriers are bracing for the worst. Physicians in all specialties are seeing professional liability rates skyrocket for the first time in many years. It’s a grim reminder of when so-called malpractice crises erupted in the past, driving doctors to pay higher premiums, find replacement, and seek shelter behind defensive practice patterns.

Although ophthalmologists are not immune from current adverse developments, their loss experience is better than most other specialties and, in some cases, significantly better on average than all specialties combined. OMIC’s loss experience and financial performance continues to be more favorable than the industry as a whole. Yet claims costs and related expenses require even the most conservative carrier to periodically adjust its price. A few physician-sponsored carriers have been able to keep rate increases well under the 10% this year. OMIC, for example, will adjust its premium by 7.5% for policies issued or renewed after July 1, 2001.

The news unfortunately isn’t as good for other physicians. Double-digit rate hikes are back. Many medical malpractice carriers anticipate or have already instituted premium increases that may well exceed the expected national average of 15%. Commercial (non-provider-owned) carriers seem the hardest hit with planned increases of 50% to 100% in some states. Although the relative rate for an ophthalmologist is less than say for an OB-GYN specialist, some of these large increases may apply across the board to ophthalmologists insured by these companies. One large national carrier, which has slipped from first to fifth place as the leading provider of malpractice insurance, reportedly doubled its premiums for some ophthalmologists in Arizona, Missouri, and Texas and selectively levied a 60% increase for risks in Vermont and 75% in California. Another large national provider of physician professional liability insurance isn’t writing or renewing business at any price in Georgia, sending many of its longtime policyholders and insurance brokers scrambling to find replacement coverage.

Physician-owned or sponsored insurers seem to be faring better. Rate announcements from doctor-owned carries range from no increase to 30% with some 40% to 50% increases in so-called problems states such as West Virginia. Insurance companies there were created by medical societies and governed by physicians mushroomed in the 1970s and 80s in response to capacity and affordability problems during prior hard markets. Collectively, these companies now provide professional liability coverage to nearly two-thirds of the physicians in the U.S. Based on year-end 2000 financial statements, this physician-controlled segment of the insurance industry has generally done better than the medical malpractice industry as a whole., which includes the large commercial stock companies.

Rapidly Deteriorating Market
In a recent study, a leading research analyst for the insurance industry, Conning & Company, warned that the financial condition of the medical malpractice insurance business is rapidly deteriorating with “no margin for negative surprises.” Looking at the industry as a whole, it estimates a huge deficiency in malpractice claims reserves to the tune of a staggering $1.7 billion. This degree of adverse development clearly doesn’t happen overnight. Conning suggests the problem began as early as 1993 when the severity of incidents, accelerating claims payments, and increasing defense costs started to climb. Of particular concern as the rising incidence of claims alleging failure to diagnose and medication-related errors. Ophthalmologists should not be quick to assume that such problems don’t apply to them. A number of OMIC’s largest settlements have related less to the science and practice of ophthalmology and more to general medical problems such as failing to diagnose cancer or failing to adequately track and follow up on urgent care. Clearly, failure to follow some of the most basic risk management principles of general medical practice could have a more crippling effect on overall ophthalmic loss experience nationwide than some of the newer refractive procedures such as LASIK, which to date show only low to moderate claims severity.

What’s causing this deterioration and why does it seem to be occurring so suddenly after years of declining malpractice rates and aggressive competition? For at least the past five years, many medical malpractice carriers have had a voracious appetite for market share. This has had the effect of driving prices down even though combined and operating ratios for the industry as a whole were locked in a steady upward creep. Fortunately, physician-owned/sponsored carriers such as OMIC have been able to maintain more stable and consistent ratios during this period.

Nevertheless, during these “soft market” conditions, the financial results of carriers were propped up by good investment returns, favorable reinsurance deals, and better-than-expected loss results from prior policy years, which allowed companies to reduce their reserves and increase surplus. In the background, however, malpractice claims severity continued to grow. Defense costs kept rising, reserve takedowns on older policy years began to dry up, investment returns started to shrink, but premiums on the most part remained the same. Malpractice carriers were still locked in a battle to gain a shrinking market share. Artificially depressed rates prevailed until the damn burst at year-end 2000.

Loss Ratios Worsen
Every spring, insurance carriers file detailed financial statements showing the results of their operations through December 31 of the previous year. As analyst look at these year-end 2000 statements, a collective picture of the industry began to emerge. Their suspicions during the past 24 months are being confirmed. The approaching “hard market” has finally arrived. Loss ratios, which measure a company’s loss experience in relation to its total book of business, jumped nearly 10 points in one year to approximately 100% for all doctor-owned carriers combined. Analysts expect the numbers to be worse when large independent carriers are included in the mix. (OMIC’s loss ratio in comparison increased only 2.5% to 79.9% at year-end 2000.)

Other ratios that analyst use to measure an insurer’s operating performance also worsened during the past year. The combined ratio, which measures a company’s overall underwriting profitability before investment returns, climbed to 125% for the provider-sponsored carriers and 134% for the entire industry. However, after factoring gains on investments, carriers still showed relatively acceptable (albeit increasing) operating ratios. An operating ratio of less than 100 indicates acceptable financial health for a carrier because it is still able to show a profit from its core business. The average operating ratio for all doctor-owned carriers combined was 95.6% at year-end 2000. (OMIC reported a combined ratio of 119.3% and a favorable operating ratio of 91%.)

More Ominous Signs for Some Carriers
Unfortunately, we are now starting to see a number of long-standing carriers having difficulty even measuring up to the average. Data from financial filings for year-end 2000 indicate that between one-quarter and one-third of provider-sponsored medical malpractice carriers may show an operating ratio of greater than 100% and could report negative operating cash flow. A handful of companies may even show operating ratios in excess of 120%. A number of large independent commercial carriers also are facing significant challenges. The health care unit of one of the leading national medical liability carriers reported a year-end 2000 combined ratio of almost 130% and a fourth quarter combined ratio of nearly 160%. A large hospital association carrier reported a combined ratio last year of 200% as well as receiving two rating downgrades by A.M. Best Company in as many years.

Even if an improving U.S. economy turns Wall Street bullish again, it’s clear that it will take more than higher returns on investments to reverse the deterioration of some segments of the medical malpractice insurance industry. Insurance carriers will have to invoke a number of tough and unpopular remedies to exorcise the demons of the hard market of 2001. Here’s what ophthalmologists and doctors in all specialties can expect:

• Higher malpractice premiums for the near future. The size of increases will vary by carrier and depend on an individual company’s financial performance and overall profitability. OMIC anticipates a more modest fluctuation in its rates compared to the industry because it has historically kept rates a level sufficient to support its ability to pay claims over the long term.
• Tougher underwriting and cancellations of policies that carriers deem unprofitable. Some carriers appear to be engaged in wholesale cancellation of policies based primarily on geography, claims history, and scope of practice. Some uninsured ophthalmologists have called OMIC with stories of physicians being dropped because they were doing refractive surgery or had just one claim. OMIC plans to continue underwriting physicians in the same prudent manner it has in the past, relying on its historical success of selecting insureds who ultimately contribute to loss results that are consistently better than the industry.
• Fewer discounts and lower dividends. Cash-strapped carriers may become less generous with premium discounts to raise much needed revenue. Last year, the surplus of all companies combined fell for the first time in recent history. Shrinking surplus and smaller or nonexistent reserve takedowns could mean lower dividend payouts in the future. OMIC’s surplus did not decrease last year and was maintained as the same conservative level as the previous year. OMIC also is continuing its cooperative ventures with a dozen state and subspecialty societies and provides a special 10% premium discount for participating in cosponsored risk management programs. As in the past, dividends will be determined each year based on annual performance results.
• Claims costs will continue to increase unless controls are employed. Despite the cyclical nature of insurance markets and litigation, claims severity will continue to grow unabated unless doctors and carriers employ proven measures to stem the tide.
  • Tort Reform — First and foremost, efforts to bolster state tort reform initiatives are critical to keeping claims indemnity under control. According to Jury Verdict Research, jury awards in malpractice cases jumped 7% in 1999, raising the median award to $800,000. During previous, “medical malpractice crises,” the most common factor associated with markedly improved loss experience was the existence of strong tort reform measures with an effective cap on noneconomic damages (pain and suffering).
  • Risk Management — Despite the temptation to reduce costs by cutting back on operational expenses, such as risk management, carriers instead need to provide more resources for these activities. OMIC will continue to make its ophthalmic-specific risk management activities available to policyholders and members of the American Academy of Ophthalmology and anticipates extending these activities through the Internet and other means.

Why Some Carriers Can Withstand a Hard Market
Perhaps the silver lining in this hard market is that physicians and their professional liability carriers have been down this road before. What we’ve learned from previous hard markets is that such a condition is not so much a malpractice crisis as it is a cycle. Fortunately, cycles turn, but their duration can clearly be impacted by how quickly and how well we respond. Physicians who didn’t chase some of those irresistibly cheap rates in the past and stayed with a strong and reasonably priced insurer are now in a better position to ride out the hard market with their current carrier. Companies that previously engaged in predatory pricing tactics to gain market share may now have to play “catch-up” by significantly boosting rates to meet the future demands of rising claims. Others, such as OMIC and those physician-sponsored carriers that remained focused on their original mission and purpose, are likely to successfully ride out the current storm as well as provide opportunities to those doctors now forced to search for a new carrier that can better support their long-term insurance needs.

In the future, adverse market cycles might be broken if some carriers choose to learn from the past and resist the temptation to feed their egos and corporate appetite for market domination and growth at any cost.

Disability Insurance Works When You Can’t

By Geri Layne Craddock, CLU
Vice President at Seabury & Smith, Washington, DC

[Digest, Summer 2001]

Have you ever stopped to consider how you would maintain your income if you were to suffer a disabling accident or illness? Many people believe that Social Security would be enough to protect them if they could not work. In fact, Social Security contains a very narrow definition of disability under which many situations are not covered. Additionally, Social Security benefits often are considerably less than private or group insurance benefits.

Workers’ compensation insurance should not be confused with disability insurance: workers’ compensation covers only disabilities that occur on the job. Disability plans offered by employers vary considerably in coverage length and percentage of salary that is covered. Many employers do offer disability insurance, but often it’s short-term coverage-generally one to five years-and may be grossly inadequate for those who suffer a long-term disability, such as paralysis or back injury.

At first glance, the cost of disability insurance might seem high. But it is important to remember that this is basic and essential insurance protection for people who rely on their regular income. According to the U.S. Census Bureau, one in five Americans were disabled in 1997.¹ The American Council of Life Insurers maintains that a 35-year-old is six times more likely to become disabled than to die before he or she reaches age 65.² Clearly, disability insurance may be even more essential than life insurance.

If you are interested in securing disability insurance, shop around and compare plans. Remember to weigh the cost against the potential benefits you would receive if you were unable to work for two, five, or twenty years. Examine these key elements as you compare policies:

Definition of “total disability.” This could be the most critical feature of your policy. Under many policies, you must be unable to perform any job for which you are qualified. One way to protect the educational investment you’ve made in your career is with own occupation coverage. Own occupation policies pay benefits if you are unable to engage in your own occupation even if you are able to return to work at a lower paying job that is not in your field. Some policies even consider a recognized medical specialty, such as ophthalmology, to be your occupation.

Length of benefits. Ideally, you should look for long-term coverage that protects you until age 65 even if you have to opt for lower benefits to keep the premiums more affordable.

Amount of coverage. To ensure that you have incentive to return to work, most plans set limits on the percentage of income you can insure, usually 50% to 60% of your total gross annual earnings. If you have an employer-provided plan that provides only limited coverage, consider purchasing supplemental coverage from another source.

Waiting period. The elimination or waiting period is the amount of time you must be disabled before your benefits begin-the shorter the waiting period, the higher the premiums.

Taxation of benefits. Benefits may be tax-free if you pay the premiums out-of-pocket, so check with your tax advisor.

Residual benefits. After a serious disability, many people return to work on a part-time basis for part-time pay. Residual or partial benefits can allow you to receive a combination of income and disability benefits until you fully recover. Without this feature, your benefits would most likely stop as soon as you return to work.

Financial strength of the insurance company. Find out as much as you can about the insurer. High ratings from A.M. Best Company, Standard & Poor’s, Moody’s Investors Service, or Fitch Ratings are good indicators of financial strength. Each of these independent rating companies have web sites where you can access information about various insurance companies.

Portable coverage. Having your own policy outside of your employee benefits allows you to move from practice to practice without fear of losing your coverage. Association-sponsored insurance is an excellent resource for that reason.

A valuable benefit of your Academy membership is your access to its many sponsored insurance programs, which have been individually tailored to meet the specific needs of ophthalmologists.

If you would like an information kit sent to you on the Academy’s Group Disability Income Plan,³ including plan features, cost, eligibility, renewability, limitations, and exclusions, call Seabury & Smith, the Academy’s life and health insurance administrator, at (888) 424-2308.

Notes:

1. Taken from www.census.gov.
2. Taken from www.insure.com/health/longtermdisability.html.
3. Underwritten by New York Life Insurance Company, 51 Madison Avenue, New York, NY 10010.