Term
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Definition
| A statement believed to be true to the best of one's knowledge |
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Term
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Definition
| Insurance purchased by an insurance company from another insurance company as a means of risk management or spreading the risk |
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Term
| Residual disability benefit |
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Definition
| While not totally disabled, the policy will pay the insured a portion of his lost income if he is not able to work as much or is forced to work at a job that pays less |
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Term
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Definition
| Type of health ore medical care designed to provide a short rest period for a caregiver |
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Term
| Reasonable and customary charge |
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Definition
| Charge for health care service consistent with the f=going rate of charge in a given geographical area for identical or similar services |
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Term
| Recurrent disability provision |
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Definition
| A disability income policy provision that species the period of time during which the reoccurrence of a disability is considered a continuation of a prior disability |
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Term
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Definition
| A mandatory NAIC provision stating that the insured must submit a completed claim form with documentation of loss to the insurer within 90 days of the date of loss |
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Term
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Definition
| Insurer reviews all proposed nonemergency hospital admissions and requires approval before admission |
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Term
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Definition
| The reason for the loss(fire, wind, hail, and so forth) |
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Term
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Definition
| An illness or medical condition that existed before a policy's effective date |
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Term
| Preferred provider organization |
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Definition
| Association of health care providers, such as doctors and hospitals, who agree to provide health care to members of a particular group at a discounted rate |
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Term
| Preferred, standard, substandard, or decline |
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Definition
| The four ways risks are classified |
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Term
| Presumptive disability benefit |
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Definition
| Regardless if the insured is able to work, he is eligible for full disability benefits if he has complete loss of speech, hearing, vision or the loss of use of two or more limbs |
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Term
| Primary insurance amount (PIA) |
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Definition
| Amount equal to a covered worker's full Social Security retirement benefit or disability |
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Term
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Definition
| The amount under an AD&D policy that is payable as a death benefit if death is due to an accident |
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Term
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Definition
| A period of time between the issuance of a policy and the date coverage begins (sickness is not covered during this time) |
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Term
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Definition
| Illness or injury preventing insured from performing at least one or more, but not all, of the insured's occupational duties |
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Term
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Definition
| A definition of total disability. The insured must be unable to work at her own occupation. It is easier for the insured to receive benefits under policies using this definition |
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Term
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Definition
| This element of a contract is either made by the applicant (when an application is completed and premium is submitted) or is made by the insurance company (when no premium is submitted with the application) |
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Term
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Definition
| A network of physicians who work out of their own offices and participate in the HMO on a part-time basis |
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Term
| Notice of claims provision |
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Definition
| Mandatory NAIC provision that describes the insured's obligation to provide notification of loss to the insurer within a reasonable period of time |
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Term
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Definition
| Pays on the basis of what is considered usual, customary, and reasonable in a certain geographical area and based on amount physicians in area usually charge for same of similar procedures |
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Term
| Non-cancelable renewal provision |
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Definition
| This renewal provision is most favorable to the insured as the insurer cannot cancel coverage (except for nonpayment of premium) nor increase the premium |
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Term
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Definition
| Requires medical care, but does not result in loss of time from work |
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Term
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Definition
| The relative incidence of disability due to sickness or accident within a given group |
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Term
| Misstatement of age or sex provision |
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Definition
| If insured's age or sex is misstated in an application for insurance, the benefit payable is adjusted to what the premiums paid should have purchased |
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Term
| Multiple employer trust (MET) |
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Definition
| Several small groups of individuals that need life and health insurance but do not qualify for true group insurance band together under state trust laws to purchase insurance at a more favorable rate |
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Term
| National Association of Insurance Commissioners (NAIC) |
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Definition
| Association of state insurance commissioners active in insurance regulatory problems and in forming and recommending model legislation and requirements |
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Term
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Definition
| Private insurance coverage for prescription drugs which is subject to Medicare rules |
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Term
| Medicare supplement policy |
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Definition
| Health insurance that provides coverage to fill the gaps in Medicare coverage |
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Term
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Definition
| Hospitalization insurance that provides specified in-hospital and related benefits. Hospital admissions are subject to a deductible and possible co-pays |
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Term
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Definition
| Covers physicians and outpatient treatment, subject to a monthly premium, annual deductible and coinsurance |
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Term
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Definition
| A department found within an insurance company that reviews applications to evaluate risk and eliminates those that do not meet standards |
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Term
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Definition
| Definition of disability where the insured is unable to work |
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Term
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Definition
Managed care organizations may control hospitalization costs by methods:
-Prospective review:Pre-approval before admission
-Concurrent review: Continuing review during the period of hospitalization |
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Term
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Definition
| A unique characteristic of insurance, stating insurers are required by law to pay legitimate claims where the policy owner is not required by law to pay a premium. Only insurer makes legally enforceable promise |
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Term
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Definition
| Limits the maximum out-of-pocket expense an insured must pay for health care and once the threshold has been met, the health insurance policy covers all expenses for the remainder of the year at 100% |
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Term
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Definition
| Person sho is considered an under-average or impaired insurance risk and is charged a higher than standard premium |
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Term
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Definition
| Medical care leading to recovery which is received on a daily basis |
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Term
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Definition
| List of cash allowances payable for various types of benefits which does not imbrues the insured for actual expenses but pays what is listed |
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Term
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Definition
| Restrict benefits to specified accidents or diseases, such as travel policies, dread disease (cancer) policies, and so forth |
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