Glossary Terms-Health

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Glossary Terms-Health
2012-08-10 17:53:19
Nevada Health Insurance Basics Beyond

Glossary terms-Health
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  1. Common Accident Provision
    provides that covered medical expenses for all family members injured in the same accident will be subject to only one deductible, rather than a deductible for each person
  2. Community-Based Care
    services provided outside the institutional setting, e.g., home health care (home-delivered nursing services or therapy), home care services (services of a personal nature including home and chore aid services, nutritional services, and assistance with activities of daily living), respite care and adult day care (full-time care provided in a patient's home or day care facility during the day to allow the primary care giver to work)
  3. Comprehensive Major Medical Policies
    incorporates coverage of major medical and basic medical expense policies into one policy
  4. Concurrent Review
    monitoring of health care services while the insured is receiving treatment to assure that the care is necessary and cost effective
  5. Conditional Contract
    a contract in which a party must perform only if specified but uncertain events occur.  In insurance, the insurer must pay claims only if a covered injury or illness occurs and proper claims are submitted
  6. Conditional Receipt
    a receipt for the premium that provides coverage is in effect as of the date the initial premium was paid, if the application is approved (shows a standard risk)
  7. Consideration Clause
    states that the consideration for the policy is the statements made by the applicant on the application and payment of the premium; sets forth the amount of initial and renewal premiums and the frequency of future payments
  8. Consumer-Driven Health Plans (CDHP's)
    combines a high-deductible health plan (HDHP) with a tax-advantage health reimbursement account (HRA), health savings account (HSA) or medical savings account (MSA)
  9. Contingent Benefciary
    alternate beneficiary designated to receive payments if the primary beneficiary dies before the insured dies
  10. Contract
    • four elements (CLOC) required to create a contract are
    • Compentent parties (sane)
    • Legal
    • Offer and Acceptance (insured applies and insurer issues policy)
    • Consideration (statements made on the application for insurance and the payment of premium exchange for promise to pay claims)
  11. Contributory Group Plan
    group insurance where members pay at lest a portion of the premium.  75% of eligible members must participate in such a plan
  12. Coordination of Benefits Provision
    provision found in group health policies which provides that when a person is covered by more than one plan, one plan will be primary and pay up to its limits, and other plans will be secondary (excess) and pay up to their limits or the remainder of the total covered expenses, whichever is less (e.g., policy covering employee is primary over policy covering dependent of enmployee; policy covering parent whose burthday is first during the year provides primary coverage for children)
  13. Corridor Dedutible
    deductible imposed in a supplemental major medical policy after basic benefits are exhausted and before major medical benefits apply
  14. Cost-Of-Living Rider
    rider added to a disability income policy that automatically increases the monthly benefit amount periodically based on the increase in a cost-of-living index
  15. Deductible
    an amount of covered expenses that must be paid by an insured before the policy begins to pay benefits
  16. Dependent Children Benefits
    group policies cover children from the moment of birth, cover birth defects, cover newborn infants and adopted children on the same basis as other dependents; iof a child is dependent on the insured for support and unable to support him/herself because of a disability or handicap, coverage must continue for the child past the limiting age
  17. Disability
    a physical or mental impairment which partially or totally limits one's ability to perform occupational duties; definitions of disability will vary from policy to policy and among government benefit programs
  18. Disability Buyout Policy
    provides business partners or officers with a lump sum or installment income necessary to buy out the interest of a disabled partner or officer
  19. Disability Income Insurance Exclusions
    policies often exclude loss caused by war, military service, intentionally self-inflicted injury, resulting of committing a felony, and loss while serving as crew member or pilot of an aircraft
  20. Disability Income Policy
    a policy that proides periodic payments when the insured is unable to work as a result of illness, disease or injury.  Usually requires total disability, has a probationary period for sickness benefits, and has an elimnation period to be satisfied for each disability.  Benefits are subject to maximum limits based on the smaller of a flat dollar amount or a percentage of the insured's earnings (not including interest or other income not affected by an inability to work)
  21. Dread Specified Disease (limited) Benefits
    provides protection only against specifically designated accidents or illnesses; provides unallocated blanket reimbursement of expenses incurred for the treatment of the specified diseases, up to a specified maximum amount; low premium amount, but low probability of loss
  22. Elimination (waiting) Period
    the duration of time after the start of each disability before disability income benefits are payable; a form of deductible, e.g., with a seven-day waiting period, the policy will pay no benefits unless the disability lasts longer than seven days
  23. Entire Contract
    the policy, endorsements and attached papers (including the application), if any, constitute the "entire contract"; changes must be approved by an executive officer of the insurer and endorsed or attached to the policy; a producer cannot change the policy or waive provision
  24. Fair Credit Reporting Act
    a federal law designed to protect the privacy of consumer report information and guarantee that information supplied by credit reporting agencies is an accurate as possible.  Gives the consumer certain rights,such as correcting incorrect information on a consumer report
  25. False Claims
    wholly or partially untrue or deceptive attempts to cause a health care payor to make a payment for health care services
  26. Family Deductible
    limit placed on the total of the individual deductibles that may be paid by the fanmily during the calander year
  27. Free Look
    required by law, this provision allows the policyowner of a health policy 10 days from the date of receipt of a policy (30 days for long-term care and Medicare supplement insurance), to inspect it and return it for a full refund of the premium paid, if dissatisfied for any reason
  28. Gatekeeper
    a primary care physician (PCP) who controls the use of services and refers partcipants to specialists within a managed care network
  29. Grace Period
    • the policy will stay in force during a grace period of seven days after a weekly premium is due, 10 days after a monthly premium is due, or 31 days after any other premium is due
    • seven=weekly
    • 10=monthly
    • 31=other
  30. Group Disability Income Policy
    a policy, usually paid for by an employer as a fringe benefit, providing income benefits of less than 70% of earnings.  Premiums are not taxable, but benefits are taxable as income to the employee
  31. Guaranteed Insurability Rider
    when added to a disability income policy, it allows an insured to buy specified added benefit amounts without proof of insurability at specified times up to a specified age
  32. Guaranteed Renewable
    policies which give the insured the right to continue the policy in force (by paying the premiums) for a substantial period of time during which the insurer cannot cancel or unilaterally make any change in the contract, but can change the premiun rate for an entire rating class of insured (but not just for an individual)
  33. Health Care Services Contractor
    a corporation, cooperative group, or association sponsored by or connected with a provider or group of providers (doctors or hospitals),which is not otherwise engaged in the insurance business, and which accepts prepaymennt for health care services
  34. Health Insurance Portability and Accountability Act (HIPAA)
    enables individuals changing jobs to obtain group health and coverage without having to satisfy a new pre-existing conditions provision and/or a new probationary period
  35. Health Maintenance Organization (HMO)
    health care centers which stress preventive health care, early diagnosis and treatment on an outpatient basis.  Provides a broad range of services for a fixed period payment and nominal service chare (copay)
  36. Home Health Care
    nursing care, theraly, and home health aide services provided in the insured's home
  37. Hospice
    a faciliyt that provides services for support and relief of pain for terminally ill persons
  38. Hospital Expense Insurance
    provides benefits subject to a specifed daily maximum for a specified period of time while the insured is confined to a hospital, plus a limited allowance up to a specified amount for miscellaneous hospital expenses, e.g., operating room, anesthesia, laboratory fees, etc.
  39. Hosptial Indemnity Insurance
    a form of disability income insurance that provides a specified daily benefit while an insured is hospitalized, regardless of the actual hospital expense; is paid in addition to medical expense coverage benefits
  40. Illegal Occupation
    allows the insurer to deny payment for any loss to which a contributing cause was the insured's commission of, or attempt to commit, a felony, or engaging in an illegal occupation
  41. Incontestability (time limit on certain defenses)
    after two years no misstatements, ezept fraudulent ones, may  be used to void the policy or deny a claim
  42. Individual Deductible
    an amount each individual insured must satisfy before major medical benefits will be paid
  43. Inflation Adjustment
    automatically increases benefits at a specified rate (at least 5%)
  44. Initial Deductible
    deductible of a fixed (flat) amount that must be satisfied before policy benefits apply
  45. Institutional Care
    care provided in a hospital, skilled or intermediate nursing home, congregate care facility, adult family home, or other stated-certified or licensed facility which performs diagnostic, preventive, therapeutic, rehabiliative, maintenance or personal care services, and which provides 24-hour nursing services on its permises or in facilityes available tothe institution on a formal prearranged basis
  46. Insurable Interest
    in life or health insurance, an interest existing when one person would reasonably benefit from the continuance of another person's life or good health or would suffer a financial or emotional loss at his death  or disability.  In life or disability insurance, a person is considered to have an unlimited insurable interest in himself; if the policy is purchased by someone other than the insured, the beneficary must have the insurable interest at the time of application (but the interest need not exist later)
  47. Insurance with Other Insurers
    the insurer is liable only for its pro rata share of the total amount payable under all applicable coverages, if the insurer had not been notified in writing of the other coverage.  Applies to individual policies
  48. Insuring Claus (agreement)
    defines and describes the scope of the coverage provided and the limits of indemnification; the benefits cited in the policy
  49. Integrated Deductible
    specified deductible found in supplemental major medical policies which may be satisfied by the basic policy
  50. Irrevocable Beneficiary
    beneficiary who cannot be unilaterally changed by the policy owner and without whose consent the policyowner does not have the right to change beneficiaries
  51. Key employee Coverage
    a form of disability income insurance which provides a business with income to cover the loss of services of a key employee, partner, officer, etc.
  52. Legal Actions
    an insured cannot sue for payment before 60 days after furnishing proof of loss or after three years after furnishing such proof
  53. Long-Term Care
    covers care ranging from custodial to skilled nursing care provided on a long-term basis in a nursing home or in the insured's home; cannot exclude Alzheimer's disease; must cover services from nursing home, assisted living, home care, adult foster care
  54. Major Medical Expense Insurance
    policies designed to help offset heavy medical expenses resulting from catastrophic or prolonged illnesses or injuries. Provides large maximum benefit amounts, relatively large deductibles paid by the insured, percentage participation (coinsurance) of 75%-80% of medical expenses after thedeductible, and wide range of coverage of medical services (but typically exclude routine checkups, eyeglasses,injuries from war, intentionally self-inflicted injury, disabilities covered by workers compensation, treatment ingovernment facilities, cosmetic surgery [unless required as a result of an accident or illness], and pre-existing conditions during probationary period).
  55. Managed Care
    management of financing and delivery of health care through cost-control techniques, sharing of financial risk between providers and consumers, and management of the use of the health care services.
  56. Mandatory Provisions (Uniform)
    provisions required by state status to be in all health insurance contracts (taken from the model provision provided by the National Association of Insurance Commissioners (NAIC))
  57. Mandatory Second Surgical Opinion
    a requirement in a health insurance policy that a second doctor’s opinion be obtained as to the need for an operation in order for full surgical benefits to be paid for certain types ofoperations; provides for reduced benefits if the second opinion is not obtained; provides for payment of the cost ofthe second opinion itself.
  58. Medicaid
    a welfare program administered by the states and subsidized by federal government grants, providing forpayment of various medical expenses for those whose income and resources are below limits set by varying statelaws. In Oregon, Medicaid is the Oregon Health Plan.
  59. Medical Expense Insurance
    forms of health insurance that include payment for costs of health care
  60. Medical Expense Policy Exclusions
    typical exclusions are injury or disability from war, disability resulting from military duty (even if not during war), intentionally self-inflicted injury, dental expenses, cosmetic surgery and expenses, vision care (eyeglasses), hearing care (hearing aids), and care in government facilities.
  61. Medicare
    • a federal government program paying certain hospital and medical expense benefits for persons in the U.S. over age 65, and certain persons under age 65 with qualifying disabilities. Part A provides hospital benefits financed by a compulsory payroll tax on all covered Social Security workers. Part B provides optional medicalexpense benefits paid by federal tax funds and voluntary contributions (premiums). Part C (Medicare Advantage)governs the way Medicare benefits are provided by companies (HMOs, PPOs, private fee-for-service plans [PFFS] andMSAs) that contract with the Medicare program. Part D pays for prescription drugs.
    • A=hospital svcs
    • B=Dr
    • C=governs the way Medicare benefits are provided
    • D=pays for rx's
  62. Medicare Supplement Policies
    policies that cover gaps in Medicare coverage (i.e., deductibles, coinsurance, charges above the Medicare limits, and costs of additional uncovered services)
  63. MIB Report
    (Medical Information Bureau) a report of medical information gathered from insurers about an applicant.  It will not contain results of underwriting
  64. Misstatement of Age
    if the insured has misstated his age, the amounts payable under the policy will beadjusted to those that the premium paid would have purchased had the insurer known the correct age.
  65. Mode of Premium Payment
    frequency with which premiums are paid (annually, semi-annually, quarterly, etc)
  66. Multiple (double, triple) Indemnity Rider
    may be added to a life policy to double or triple the death benefit, depending on the rider, in the event of a death caused by an accident
  67. Noncontributory Group Plan
    group insurance where members do not contribute to premium payments  100% of eligible members must participate.
  68. Noncancelable (noncancelable and Guaranteed Renewable)
    policies which give the insured the right to continue the policy in force (by paying the premiums) for a substantial period of time during which the insurer cannot cancel or unilaterally make any change in the contract or change the premium rate.
  69. Non-Occupational Insurance
    covers off-the-job accidents and sickness; does not cover disability resulting from injury or sickness
  70. Notice of Claim
    the insured must gfive written notice of claim to the insurer within 20 days after the occurrence of a covered loss, or as soon thereafter as is reasonably possible
  71. Occupational Policy
    insures a person against both off-the-job and on-the-job accidents or sicknesses
  72. Optional Provisions (Uniform)
    provisions that are allowed by state statute to be included in disability insurance policies, if in the same wording as provided by the statute (taken from model provisions provided by theNational Association of Insurance Commissioners [NAIC]), or contains language at least as favorable as found in the state statutes.
  73. Optionally Renewable
    policies that allow the insurer to terminate coverage at any anniversary (or premium due) date but do not allow the insurer to terminate coverage at other times
  74. Other Insurance in this Insurer
    more than one policy through the same insurer. The insurer may include one of the following two provisions: (1) if the total amount of insurance with the insurer exceeds a maximum stated in the provision, the excess is void and all premiums paid for the excess coverage will be refunded;(2) if the insured has more than one policy with the insurer, the insured, his beneficiaries or estate may elect th epolicy under which benefits are to be paid and the other policies will be void with premiums paid for them refunded;applies to individual policies.
  75. Outline of Coverage
    must be given to an applicant at time of the application or with an individual policy. It shows categories of coverage and purposes; principal benefits; exceptions, reductions and limitations; renewalprovisions; and advises that the actual policy be consulted for governing provisions.
  76. Partial Disability
    disability which prevents the insured from performing some, but not all of the duties of hisoccupation; usually benefits are paid only when the partial disability follows a period of total disability; exact degreeof disability to qualify for partial disability benefits depends on the terms of the policy; benefits are generally 50% ofthe total disability benefit and are payable for up to six months
  77. Payment of Claims
    claim payments for loss of life are to be made to the designated beneficiary, or to theinsured’s estate if there is no beneficiary; other accrued payments may be paid at the insurer’s option to thebeneficiary or to the insured’s estate; all other payments are payable to the insured. Up to $1,000 may be paid to arelative or beneficiary of the insured to cover immediate expenses when the payment is to be made to the estate or aminor. The insurer may have the option of paying the payments directly to the hospital or person rendering medicalservices unless the insured requests otherwise; but the insurer cannot require the service to be performed by aparticular hospital or person.
  78. Per-Cause (per-disability, per-occurence) Deductible
    deductible which must be satisfied for each separate illness or injury
  79. Permanent Disability
    disability from which the insured is not expeted to recover, e.g., loss of a limbg, terminal illness, etc.
  80. Physical Examinations and Autopsy
    the insurer has the right to examine (at its own expense) the insured when and as often as is reasonably required during a pending claim and make an autopsy where it is not forbidden by law
  81. Pont-of-Service (POS) Plan
    allow enrollees to choose services from a participating provider or from a non-participating network provider (at higher cost)
  82. Precertification (pre-Authorization)
    a cost-containment provision which requires that the insured obtain an evaluation from an insurer's representative to determine whether hospitalization is needed and how much of the hospitalization will be covered
  83. Pre-Existing conditons
    physical conditions existing prior to the effective date of the policy. Coverage may be denied if the condition required treatment within a specified period before the application date and then requires treatment within a specified time (probationary period) after the policy effective date; or if revealed on theapplication, if a “waiver for impairments” excludes the condition from coverage.
  84. Preferred Provider Organization (PPO)
    an organization of doctors and hospitals providing healthservices at a reduced cost. Persons who sign up for PPO services can use providers listed in the PPO or outsideproviders but receive greater coverage (lower deductible or lower coinsurance) if they use the PPO providers.
  85. Presumptive Disability
    specified disability which is automatically presumed to be total; e.g., loss of two or more limbs, speech, sight, hearing, etc.; insured would be entitled to a disability income benefit regardless of hisability to work if he suffers from such a disability.
  86. Primary Beneficiary
    beneficiary designated by the insured as being the first in priority to receive policy proceeds 
  87. Primary payor
    Medicare is the primary payor when other coverage is an individual policy or a Medicare carveoutplan (in a small group) or Medicare supplement policy. Also designates which carrier would be the first, orprimary, payor of a claim in the event more than one policy provides coverage
  88. Principal Sum
    a lump-sum benefit paid by an AD&D policy in the event of the accidental death or accidental multiple dismemberment of the insured
  89. Probationary Period
    (1) a specified number of days after the date of the issuance or reinstatement of ahealth policy during which there is coverage for accident or injury but not for sickness. Sickness protection becomeseffective only after the end of the probationary period. Used to reduce the number of claims for sickness which mayor may not have been pre-existing and helps to prevent adverse selection on the part of persons who know they are inill health; (2) a specified period which an employee must be employed full-time before being eligible for groupinsurance coverage.
  90. Proof of Loss
    the insured has 90 days from the date of the loss to submit written proof of loss to the insurer’soffice; this is extended to up to one year, if it is not reasonably possible to submit proof earlier, and indefinitely whenthe insured lacks legal capacity or is considered legally incompetent.
  91. Recurrent Disability
    disability which results from the same or a related cause of a prior disability; handledas part of the prior claim (without a new elimination period) if the recurrence is within a specified period from theend of the prior disability (e.g., six months); handled as a new claim if the recurrence is beyond that period.
  92. "Regular" Medical Expense Policies
    pays physician's fees for in-hospital, home and office visits other than for surgical procedures
  93. Reinstatement
    a premium payment accepted by the insurer or its authorized producer after the grace periodwill, if no application for reinstatement is required, reinstate the policy. If an application for reinstatement isrequired and a conditional receipt is given for the premium, the policy will be reinstated upon approval of theapplication or on the 45th day after the receipt was given, unless the application is disapproved prior to that day.  Upon reinstatement, there is a 10-day probationary period for sickness but immediate coverage for accident. The premium for reinstatement may be applied to cover unpaid premiums for up to 60 days prior to reinstatement.
  94. Reinstatement of Used Benefits
    restores benefits in full, after the insured has been out of a nursing home for six months. Also may apply to individual and group medical expense insurance, whereby at renewal of thepolicy some or all of the benefits used during the prior year are reinstated for the renewal year.
  95. Relation of Earnings to Insurance
    may only be used in disability income policies which areguaranteed to be renewable by the insured until at least age 50, or at least five years for a policy issued after age 44.If total income benefits exceed the insured’s monthly earnings at the time of disability or his average monthlyearnings during the two years prior to the disability, whichever is greater, the insurer is liable only for aproportionate share of its benefits based on the insured’s monthly earnings in relation to the total amount of coverage(e.g., the insured is earning $2,000 per month prior to his disability; he has two policies each providing benefits of upto $1,500 per month; since his earnings are 2/3 of the total coverage, each insurer is liable for only 2/3 of $1,500, or$1,000).
  96. Renewability Provisions
    provisions that relate to the insured and insurer's rights to cancel or renew policies
  97. Representations
    statements made by an applicant on the policy application that are presented as beingsubstantially true to the best of his knowledge and belief but which are not warranted as being exact in every detail.Legally, all statements made by the applicant are considered, in the absence of fraud, to be representations.
  98. Residual Disability
    disability income benefit based on the proportion of income the insured has lost as a result of a partial disability; e.g., f the insured can earn only 70% of his prior earnings, the benefit would be 30% of the disability benefit
  99. Revocable Beneficiary
    beneficiary who can be removed by the policyowner at any time and who has no rights in the policy prior to the death of the insured
  100. Secondary Payor (Excess)
    Medicare is a secondary payor when other coverage is a group plan and theemployer has at least 20 employees and the employee is over 65; or the employer has at least 100 employees and theemployee is disabled; or the employee qualifies for Medicare due to permanent kidney failure (here Medicare issecondary for the first 30 months). Also designates which carrier would be the second, or “secondary” payor of aclaim, if more than one policy provides coverage.
  101. Self-Funded Employer Plans
    geroup health plans in which the employer provides the funds to pay claims of emplopyees and their dependents.  May or may not be backed by a stop-loss insurance contract which pays all claims above a specified amount
  102. Service Organizations (prepayment plans)
    pays benefits in medical or hospital services rather than indollars (e.g., Blue Cross, Blue Shield). Prescribed medical services are provided without charge to the subscribers(other than premium payments); cash payments are made directly to the medical care provider rather than theinsureds (subscribers).
  103. Skilled Care
    care that requires training and the skills of a licensed professional nurse, is prescribed by physician, is medically necessary,  and is available on a 24-hour basis
  104. Skilled Nursing Facility
    facility that provides daily skilled nursing care and rehabilitation services, prescribed by a doctor, on a 24-hour basis
  105. Spousal Discounts
    a discount of about 10% of the cost of one or both policies, if both spouses (or in someinstances, two persons living in the same household) purchase policies at the same time. Typically applied to longtermcare contracts.
  106. Statement of Continued Good Health
    a statement that may be required by insurers upon delivery ofa policy when no initial premium had accompanied the application. In it the insured must certify that his health isthe same as it was at the time the application was submitted. If his health has changed, the policy should not bedelivered and the insurer should be contacted for further directions.
  107. Stop-Loss Provision
    places a limit on the amount of out-of-pocket expenses the insured must pay as a resultof major medical insurance requirements; e.g., may specify that after the insured has paid $1,000 as part of hiscoinsurance, 100% of covered expenses will be paid by the insurer.
  108. Subrogation
    the right of an insurer to recover the cost of the insured’s medical care from the person who injuredhim or the insurer covering that person’s liability for the medical expenses.
  109. Supplemental Major Medical Insurance
    major medical insurance designed to be added to a basicmedical insurance policy provided by the same or a different insurer. May include coverage for more types ofexpenses, longer benefit periods, higher expense limits, and fewer exclusions than the basic policy.
  110. Temporary Disability
    disability from which the insured is expected to recover after a short period of time
  111. Term (period of time)
    policies that have no proviosion for renewal or termination other than by expiration of the policy term.  A blanket policy would be a term policy
  112. Time of Payment of Claims
    payment of a claim is due immediately upon receipt of a written proof of loss
  113. Total Disability
    disability which results in a complete loss of earning power, different policies define this disability in different ways; e.g., inability to perform major duties of one's occupation, inability to perform duties of any occupation for whichone is suited, etc.
  114. Unilateral Contract
    a contract in which only one party makes any promises. In insurance, only the insurercan be sued for failing to keep the promise (to pay a covered claim). The insured does not promise to perform (paypremiums) but can only hold the insurer to his promise by performing
  115. Unpaid Premiums
    permits the insurer to deduct unpaid premiums from a disability claims payment.
  116. Waiver of Premiums
    a rider which, when added to disability income policies, exempts the policyowner frompremium payment while the insured is receiving policy benefits after a waiting (elimination) period has elapsed.Typically, premiums paid during the waiting period are refunded to the policyowner if the disability lasts beyond thespecified elimination period.
  117. Warranties
    a promise. Anything warranted to be true must be true or it can result in the policy being voided.Only the insurer is bound to fulfill a promise, which is to pay the benefits cited in the insuring agreement. If theinsurer does not honor their promise, they can be sued for breach of contract.
  118. Workers Compensation Insurance
    provides benefits for employees who suffer a loss of income as a resultofwork-related injury or illness
  119. Zero-Day Hospital Benefits
    no prior hospitalization is required before an LTC policy will cover institutional or community-based care
  120. Accident and Health Insurance
    another name for disability insurance or health insurance and includes all medical expense and disability policies.
  121. Accidental Death & Dismemberment
    provides for payment of a lump-sum death benefit (principalsum), if the insured dies as a result of an accident, and payment of a lesser sum (capital sum), if the insured suffers aloss of a hand through or above the wrist or a foot through or above the ankle joint, or the entire and irrevocable lossof sight as a result of an accident. Generally, the loss of two body members would result in payment of the capitalsum, equal to the principal sum; loss of one body member (e.g., one hand), would result in payment of half (1/2) ofthe principal sum.
  122. Accidental Means Provision
    requires that the cause of an injury must be unexpected and unintended;more restrictive and less common than “accidental bodily injury.”
  123. Adhesion
    a contract offered on a take-it-or-leave-it basis. An insured must accept an insurance policy as offeredor find another policy, as the terms are not negotiable. Since the insurer wrote the policy, if any part is unclear, acourt will rule against the insurer.
  124. Adverse Selection
    selection adverse to (against the interest of) the insurer; tendency of more poor risks than good or average risks to buy or keep insurance
  125. All-Causes Deductible
    deductible which must be satisfied only once during the calendar year, regardless ofthe causes of medical expenses.
  126. Alternative Delivery System
    health care services delivered outside of a hospital for whichhospitalization benefits may be offered as a means of reducing the cost of hospitalization, e.g., ambulatory surgicalcenters, hospice care, after care, skilled nursing facilities, home health care.
    clinics where surgery is performed on an outpatient basis.
    hospitalization, surgery and physician insurance provided on a “firstdollar”(no deductible) basis, without a coinsurance requirement, but with low coverage limits.
    person to whom proceeds of a health policy that provides death benefits are payable when theinsured dies.
     a group policy that covers a constantly changing number of individuals (on an unnamedbasis) who are exposed to the same hazards (e.g., members of an athletic team, passengers in the same mode oftransportation, etc.), so insureds do not need certificates of insurance.
  131. BLUE CROSS: 
    provides protection against the costs of hospital care. Benefit payments are made directly to thehospital. Plans may be on an individual or group basis.
  132. BLUE SHIELD: 
    provides protection against the costs of surgery and other items of medical care. Benefit paymentsare made directly to the doctor. Plans may be on an individual or group basis.
     requires that an injury be the unexpected, unintended and sudden result of anaccident; more liberal than “accidental means” benefit.
    form of disability income insurance which provides an amount to coveroverhead expenses (rent, utilities, telephone, employee salaries, etc.), while the owner is disabled; does not coverowner’s own salary or the cost of goods or inventory.
    policies that allow the insurer to terminate coverage at any time by providing at least 30 daysadvance notice and refunding unearned premiums.
    provision in major medical policies that allow expenses applied to a deductible in thelast three months of one year to be applied to the next year’s deductible.
    system of cost containment or claims control involving an analysis of the patient’s needsand monitoring of the services provided.
     summary of insurance benefits and provisions provided to members of aninsured group.
    the insured has the right to change the beneficiary, unless he has designated thebeneficiary as an irrevocable beneficiary.
     if the insured changes to a more hazardous occupation or is doing anything related toa more hazardous occupation for compensation, the insurer may reduce the benefits to those the premium wouldhave purchased at the rates for the more hazardous occupation. If the insured changes to a less hazardous occupationand notifies the insurer, the premium will be reduced and excess unearned premiums refunded.
    if an insurer requires the insured to complete proof of loss forms, it must send these to the insuredwithin 15 days after receiving a notice of claim; otherwise, the insured can file any written proof covering theoccurrence and the character and extent of the loss.
  142. COBRA (Consolidated Omnibus Budget Reconciliation Act):
     requires that employer groups of 20 or moreemployees continue group benefits for employees for 18 months after termination of employment and for dependentsof employees for 36 months after loss of dependent status (e.g., after employee dies, child is no longer dependent,spouse divorces).
  143. COINSURANCE (Percentage Participation): 
    feature of major medical policies which provides that the insurer andinsured will share covered losses in agreed proportions (e.g., if the policy has an 80% participation provision, afterthe deductible is paid by the insured, the insurer will pay 80% of the insured’s covered expenses; the insured will paythe other 20% in addition to the deductible).