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Guide to Health Claims Examining - Introduction to Technical and Legal Issues


is an agreement whereby companies collect fees or "premiums" from individuals or companies on a regular basis


paying a premium in order to continue coverage after the initial policy period has expired

Lapse in coverage

a break in continuous insurance coverage

Coverage expense

Any expense complete or partial payment is provided under the insurance policy

Accidental Death and Dismemberment Insurance

pays a benefit to the beneficiary in the event of the insured person's death by accidental means

Disability Insurance

covers and employee's salary, or a percentage of it, while the employee is on disability leave

Health Insurance

covers medical and hospital services. Such policies are sold as individual or group policies

Life Insurance

coverage on a person's life


the federal program established under Title XIX of the Social Security Act of 1965


the Federal Health Insurance Benefit Plan for the Aged and Disabled under Title XVIII of Public Law 89-97 of the Social Security Act

Worker's Compensation

a medical and disability reimbursement program that provides 100% medical coverage and a scheduled weekly disability benefit for job-related injuries

Individual Insurance

issued to insure the life or health of a named person or persons

Group Insurance

provides coverage for several people under one contract

Actuarial Statistics

studies that an insurance company uses

Third Party Administrator

professional firm that is under contract to deal solely with administering the eligibility and claim payment services for self-funded benefit plans

Human Resources Department

responsible for matters relating the company's employees

Marketing Department

responsible for presenting insurance products to the company's customers

Actuarial Department

responsible for ensuring that the company's operation are conducted on a mathematically sound basis

New Business Department

processes new business acquired by the company and Department also schedules physical examination for policies that require evidence of insurability

Premium Services Department

handles and processes all premium payments received

Underwriting Department

responsible for making sure that the premium rates are accurate and that claim payments do not exceed the amount assumed when the premium rates were calculated

Accounting Department

maintains the records to show if the company is being run in a profitable manner

Claims Department

the processing of claims in a correct and timely manner

Legal Department

makes sure that the company's operations comply with federal, state, and local laws and with the Department of Insurance regulations

Department of Insurance

entire insurance industry is overseen by a larger body


a denial or renunciation of responsibility


deception to cause a person to give up property or something of lawful right

Internal Fraud

which involves the employees of the company against which the fraud is perpetrated

External Fraud

involves people outside the company that it is directed against

Insurance Speculation

means buying insurance or coverage for the purpose of making a profit


an organized effort to discover the facts or truth of the matter


is the act of an employee illegally taking funds from a company they work for

Legal damages

are monetary awards above and beyond the benefits provided by the group plan

Compensatory Damages

are designed to compensate an insured for all of the actual losses or damages to make that person whole again

Punitive Damages

often the larger of the two awards and are intended primarily to punish wrongdoing by the defendant and make an example of them to help deter such actions in the future


as intentional conduct to cause injury or conduct that is carried on with the conscious disregard of the rights of others


demand for a witness or a document to appear

Bad Faith Awards

The dollar amount based on two concepts: (1) the degree of wrongfulness and (2) the wealth of the defendant

Conventional insurance

an employer or individual purchases an insurance plan and agrees to pay premiums to the insurance company

HIPAA Portability

the ability to transfer insurance companies and still be covered for pre-exisiting conditions

HIPAA Accountability

generally dealing with the patient's right to privacy from the medical provider, health insurer, and any other parties required in the healthcare process

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