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Health and Accident Insurance

Terms in this set (182)

health insurance
Insurance that covers loss against medical illness or accidental bodily injury. Not just medical insurance
disability income insurance (Living Death)
A form of health insurance that provides periodic payments to replace a portion of their income when the insured is unable to work as a result of illness, injury, or disease-not as a result of a work-related accident or condition
Medical Expense Insurance
A type of insurance that pays benefits for nonsurgical doctors fees commonly gotten in a hospital; sometimes pays for home and office calls
interim coverage
short-term policy purchased on an meanwhile basis, typically between jobs or waiting for a new policy to start
Accidental Death and Dismemberment
The purest form of accident insurance, It provides the insured with a lump-sum benefit amount in the event of an accidental death or dismemberment under accidental circumstances
Nonparticipating plan
Insurance in which the insured is not entitled to share the divisible surplus of the company
Participating Plan
Insurance in which the policy owner receives shares (dividends) of the divisible surplus of the company
Spendthrift Clause
Prevents a beneficiary from recklessly spending benefits by requiring the benefits to be paid in fixed amounts or installments over a certain period of time. No effect if received as one lump-sum payment
Common Disaster Provision
to provide a sequence of beneficiaries for the distribution of proceeds in the event of the short period of time death of both the insured and the primary beneficiary. The primary needs to outlive the insured for a specified period of time
Simultaneous Death Act
If the insured and the primary beneficiary die at approximately the same time for a common accident with no clear evidence on who died first, this law will assume that the primary died first, allow the benefits to be paid to the contingent
Per Capita (by the head)
evenly distributes benefits among all named living beneficiaries
Per Stirpes (by the bloodline)
in the event that a beneficiary dies before the insured, benefits of said policy will go to the beneficiaries heirs
Patient Protection and Affordable Care Act
Designed in part to increase access to care, contains provisions addressing health promotion and prevention of disease and disability that is affordable and quality
Group Health Insurance
Insurance that is available through employers, labor unions, consumed health cooperatives, and other organizations are
Renewability provision
define the rights of the insurer to cancel the policy at different points during the life of the policy. Has to have these five classifications; cancellable, optionally renewable, guaranteed renewable, and noncancellable
Cancellable Policies
Allow the insurer to terminate the policy at any time. Prohibited in most states
Optionally Renewable Policies
Allows an insurer to terminate a policy on a date specified in the contract. If the insurer decide to renew, they have the option to increase the premiums on the anniversary date
Conditionally Renewable Policies
Will only allow an insurance company to terminate a policy in the event of expressed conditions, such as age or the loss of gainful employment.. If the insurer want, they have the option to increase the premiums on the anniversary date
Guaranteed Renewable Policies
Specify that the policy Must renew, usually until the insured reaches a specified age. If the insurer want, they have the option to increase the premiums on the anniversary date. Medicare supplement and long-term care policies are the most common
Noncancelable Policies
policy can't be cancelled nor can its premium rates be increased under any circumstances. Disability policies are most common
Nonrenewable Policies
For stablished policy lengths of a year or less and are considered temporary. Usually short-term health insurance
Cafeteria Plan
benefit arrangements in which employees can pick and choose from a menu of benefits, thus tailoring the benefits package for their specific needs. Regulated by Section 125
Business Continuation Plan
provide a way to help a business continue in the event an owner or key employee dies, or in the event of a disabling sickness or injury
Special Risk Policy
Provides coverage for unusual hazards normally not covered under accident and health insurance, such as a concert pianist insuring his hands for a million dollars.
Limited Risk Policies
Provides coverage for specific kinds of accidents or illnesses, such as injuries received as a result of travel accidents or medical expenses stemming from a specified disease.
Capital Sum
Another form of payment payable under an AD&A policy. Is generally 50% of the Principal Sum. Most extreme get 100% of the principal Sum
Principal Sum (AD&D)
(face amount) pays out if death occurs. Represents the maximum amount the policy will pay
Business Overhead Expense Insurance
A form of disability income coverage designed to pay necessary business overhead expenses, such as rent, should the insured business owner become disabled.
Disability buy-sell agreement
An agreement between business co-owners that provides that shares owned by any one of them who becomes disabled shall be sold to and purchased by the other co-owners or by the business using funds from disability income insurance. Usually contains a provision allowing for a lump-sum payment of the benefit. Legally binding and usually tax-free
Key Person Disability Insurance
protection of a business against financial loss caused by the death or disablement of a vital number of the company, usually essential personal. Monthly benefit usually tax free because the premium paid is not tax deductible
Coordination of benefits
Eliminates the duplication of payments when an employee, spouse, or dependents have health coverage under two or more plans. Allows the secondary payor to reduce their benefit payments so no more than 100% of the claim is paid
Enrollment Period
The limited time period during which people, usually employees, can sign up for or change their insurance coverage.
Enrollment Card
must be completed and signed by a new employee during the open enrollment period to enroll in group insurance
Waiting Period
A period of time (often 12 months) when you are not covered by insurance for a particular problem
probationary period
Specified number of days after an insurance policy's issue date during which coverage is not afforded for sickness. Standard practice for group coverages as well as disability coverage
Health Insurance Portability and Accountability Act (HIPAA)
provides the ability to transfer and continue health insurance coverage for workers and families when they change or lose jobs. provides federal protection
Conversion Privilege
Allows the policy owner, before an original insurance policy expires, to elect to have a new policy issued that will continue the insurance coverage. Conversion may be effected at attained age (premiums based on the age attained at time of conversion) or at original age (premiums based on age at time of original issue).
preexisting condition
is an illness or medical condition that existed before a policy's effective date; usually excluded from coverage, through the policy's standard provisions or by waiver. May be excluded up to 12 months. A late enrollee is an individual who elects coverage after the initial eligibility period
Creditable Coverage
Prior coverage under another plan that hasn't been a break in coverage of 63 days. Reduced or eliminated altogether when he or she has creditable coverage
Consolidated Omnibus Budget Reconciliation Act (COBRA)
1985, legislation which extends a group health coverage to terminated employees and their families at the individuals expense for up to 18 months. Must terminate 20 employees to be eligible
Blanket Health Policies
Cover a group exposed to the same risks, but the composition of the group are constantly changing.
Franchise Health Plans (wholesale plans)
provides health coverage for small groups whose numbers are too small to qualify for true group insurance. premium rates are usually discounted
Credit Policies
designed to help the insured pay off a loan in the event they are disabled due to an accident or sickness or death. If the insured becomes disabled; the policy provides for monthly benefits payment equal to the monthly loan payments due.
Nonoccupational Coverage
The coverage provided by a Disability Income policy that does not provide benefits for losses occurring as the result of the insured's employment
Accidental Means
Unforeseen, unexpected, unintended cause of an accident. Requirement of an accident-based policy that the cause of the mishap must be accidental for any claim to be payable.
Accidental Results
policies that use the accidental bodily injury provision required that the result of the injury has to be accidental and unexpected. Far less restrictive
The Principal Sum under an AD&D
policy is the amount payable as a death benefit. Amount of insurance purchased. Represents the maximum amount the policy will pay
Capitol Sum
form of payment under the an AD&D policy and is the amount payable for the accidental loss of sight or accidental dismemberment. It is a specified amount, usually expressed as a % of the principal sum based off severity of the injury
Reimbursement Plans
pay benefits directly to the insured, who is responsible for paying the providers of medical services
Clinical Peer
someone who is in the same health care practitioner or someone who manages the same medical condition, procedure or treatment
Covered Person
Anyone who has health care coverage or employee benefit plan
Managed Care
an organized method of providing health care services and involves a third party in planning, approval and monitoring of a subscribers health care. HIC's provide such care
Capitation
Amount received by a primary care physician from the HIC. This payment is based on the number of enrollees or subscribers who have elected the physician as their primary care physician
Medicare
A federal program of health insurance for persons 65 years of age and older. It provides insurance protection to any individual who suffers from chronic kidney disease or to those who have been receiving social security disability benefits for at least 24 months. 1966
Medicaid
Title XIX (Social Security Act, 1965) purpose to provide matching federal funds to states for their medical public assistance plans to help needy persons, regardless of age. funded by federal, state and local taxes
Self- Insured Plans
The employer funds and pays for member claims and benefits. The employer therefore offer specific benefits that are best suited to employees needs. Grants the employer more control over costs and flexibility over benefits
Multiple Employer Welfare Arrangement (MEWA)
Type of MET which consists of small employers who have joined to provide health benefits for their employees, often on a self-insured basis
NCPDP SCRIPT Standard
national council for prescription drug programs
chronic condition
condition or disease that is persistent for longer than 6 continuous months
rare medical condition
any disease that affects less than 200,000 people in the US
Gatekeeper
concept utilized in an HIC and requires subscribers to choose a physician who is responsible for the subscribers health care
health care practitioners
Those who are trained to administer medical or health care to patients
Medicare part A
- Hospital Insurance covers most medically necessary hospital care, skilled nursing facilities, home health and hospice care
- Free if you have worked and paid social security for more than 10 years (40 calender quarters)
- if less than montly premium will be paid
Medicare Part B
Medical insurance. Covers: outpatient, therapy, etc. (Doctors fee)
Any Occupation
total disability that requires that for disability income benefits to be payable, the insured must be unable to perform any job for which the insured is "reasonably suited by reason of education, training, or experience."
Own Occupation
total disability that requires that in order to receive disability income benefits the insured must be unable to work at the insured's own occupation. More expensive and difficult to qualify for.
Presumptive Disability
A disability involving loss of sight, hearing, speech, or any two limbs, which is presumed to be a permanent and total disability. The insured is not required to have periodic medical examinations to prove continuing disability.
Partial Disability
illness or injury that prevents someone from performing one or more of their regular function, but not all, making it so they can't work full time resulting a decrease in income. Will collect 50% of the monthly income for 3 months or max of 6 months
Residual Amount Benefit
based on the proportion of income actually lost due to partial disability, taking into account the fact that the insured is able to work and earn some income. Usually determined by multiplying the percent of lost income by the stated monthly benefit for total disability
Elimination Period
time between the beginning of an insureds disability and the commencement of the period for which benefits are payable. Often considered "deductible" for a disability policy and is directly correlated to the premiums of the policy. If the insured wants a lower premium, they will need to settle for a long----.
Benefit Period
Maximum length of time that insurance benefits will be paid. The longer --- the higher the premium cost of the policy. Instead of charging additional premiums or excluding coverage when issuing a disability income policy to a substandard risk, an insurer may shorten this.
Delayed disability provision
A disability income policy provision that allows a certain amount of time after an accident for a disability to result, and the insured remains eligible for benefits
Recurrent Disability Provision
A disability income policy provision that specifies the period of time during which the reoccurrence of a disability is considered a continuation of a prior disability.
Continuation of Prior Disability
Most policies provide for recurrent disability is considered this
Social Security Rider
provides for the payment of additional income when the insured is eligible for social insurance benefits but those benefits have not yet begun, have been denied, or have begun in an amount less than the benefit amount of the rider
Cost of Living Rider
a rider available with some policies that provides for an automatic increase in benefits (typically tied to the Consumer Price Index) offsetting the effects of inflation
Guaranteed Insurability Rider
Additional insurance may be purchased at various times without evidence of insurability. Guarantees the insureds insurability giving them the right to purchase additional amounts of disability income coverage at predetermined times in the future without proof of good health
Rehabilitation Benefit
Facilitates vocational training to prepare insured for a new occupation.
Percent-of-Earnings approach
determines the benefit using a percentage of the insured's pre-disability earnings and takes into account other sources of disability income
Flat amount approach
specifies a flat income benefit amount that will be paid if the insured becomes totally disabled. Normally, this amount is payable regardless of any other income benefits the insured may receive. Usually 50% of the full disability benefit
Change of Occupation provision
allows the insurer to reduce the maximum benefit payable under the policy if the insured switches to a more hazardous occupation or to reduce the premium rate charged if the insured changes to a less hazardous occupation. If the insured changes to a less hazardous job, the insurer will return any excess unearned premium
Nondisabling Injury
an injury that may have resulted from an accident, but are not necessarily disabling.
Elective Indemnity Option
may be selected by the insured when applying for a disability policy. typically for short-term disability income policies and provide for an optional lump sum payment for certain named injuries
Waiver of Premium Rider
Optional rider that requires an insurer to assume payment of premiums should the insured become totally disabled for six months for the duration of the disability.
Americans with Disabilities Act (ADA)
considers major life activities to include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working
Basic Medical Expense Insurance
Health Insurance policy the provides "first dollar" benefits for specified (and limited) health care, such as hospitalization, surgery, or physician services. Characterized by limited benefit periods and relatively low coverage limits
Major Medical Expense Policy
Health insurance policy that provides broad coverage and high benefits for hospitalization, surgery, and physician services. Characterized by deductibles and coinsurance cost- sharing.
Deductible
amount of expense or loss to be paid by the insured before a health insurance policy starts paying benefits
Flat Deductible (initial deductible)
A stated dollar amount that applies to a covered loss (e.g. $500). This deductible is applied per occurrence, per insured individual
Corridor Deductible
comes into play when a major medical policy is supplementing basic coverage that contains no deductible., not applied until the basic coverage has been exhausted
Integrated Deductible
Used when a major medical plan is supplementing basic coverages. If the major medical has a $500 deductible and the insured has basic coverage of $500 or more, then, in the event of a claim, the amount paid by the basic coverage satisfied the major medical deductible. However, if the basic does not cover the entire deductible amount of the major plan, the insured is required to make up the difference. A single deductible is applied to both medical and dental
Per Cause Deductible
insured must satisfy a deductible for each accident or illness
All-cause deductible
the insured only has to meet the deductible amount once during the benefit period
Carryover Provision
allows an insured to defer current health charges to the following years deductible instead of the current years. Major Medical deductible --- period normally applies to expenses incurred during the last three months of the plan year
Coinsurance
principle under which the company insures only part of the potential loss , then policyowner paying the other part. For instance, in a major medical policy, the company may agree to pay % of the insureds expenses, with the insured paying the other %
Stop Loss
designed to stop the companys loss at a given point, as an aggregate payable under a policy, a maximum payable for any one disability, or the like; also applies to individuals, placing a limit on the maximum out-of-pocket expenses an insured must pay for health care, after which the health policy covers all expenses
Health Savings Account (HSA)
tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a high-deductible health plan (HDHP). The funds contributed to an account are not subject to federal income tax at the time of deposit.
Health Reimbursement Arrangement (HRA)
Employer -funded and established, tax advantaged health benefit plans that reimburse employees for out-of-pocket medical expenses and individual health insurance premiums. Unused amounts may be carried forward for reimbursement in the future. May be tax-free if the employee paid for qualified medical expenses or pla
Medical Savings Account (MSA)
A medical insurance plan that the employer contributes to meet the needs of the individual's medical needs. Available for employers with no more than 50 employees
Flexible Savings Account (FSA)
tax-advantaged accounts that can be set up through a cafeteria plan of an employer. allows an employee to set aside a portion of earnings to pay for qualified medical expenses (like prescriptions) as established in a cafeteria plan
hospital indemnity policy
Form of health insurance providing a stipulated daily, weekly, or monthly indemnity during hospital confinement; payable on an unallocated basis without regard to actual hospital expense. Not included under a health benefit plan
Limited Benefit Policies
restrict benefits to specified accidents or diseases, such as travel policies, dread disease policies, ticket policies and so forth
Critical Illness Policies
insurance product in which the insurer is contracted to typically make a lump sum cash payment if the policyholder is diagnosed with one of the specific illnesses on a predetermined list as part of an insurance policy
Surgical Schedule Approach
every surgical procedure is assigned a dollar amount by the insurer
Relative Value Approach
Every surgical procedure is assigned a specified set of units assigned. The policy will carry a stated-dollar per units amount (known as a conversion factor) to determine the benefit
usual, customary, and reasonable (UCR)
surgical expense is compared to what is deemed reasonable and customary for the geographical part of the country where the surgery was performed. Maximum amount an insurer will consider eligible for reimbursement under a health insurance plan
comprehensive major medical
A combination of basic coverage and major medical coverage sold as one policy. Cover practically all medical expenses, hospital physicians, surgical, nursing, drugs, laboratory tests, etc.
drug formulary
a list of prescription medications covered by a pharmacy benefit
first dollar coverage
no deductible is required before expenses are reimbursed
Medicare Supplement (Medigap)
health insurance that provides coverage to fill the gaps in Medicare coverage. Must be guaranteed renewable, however an insurer can cancel after the nonpayment of premiums.
Medicare Select Plan
type of Medicare Supplement plan sold in some states that can be any of the standardized Medigap plans (A-N) but which requires policy holders to receive services from within a defined network of hospitals and - in some cases- doctors in order to become eligible for full benefits
Medicare part D
Prescription drug benefit to help Medicare beneficiaries pay for the drugs they need. The drug benefit is optional and is available to anyone who is entitled tp Medicare part A or enrolled in part B. Benefit is available through private prescription drug plans (POPs) or Medicare Advantaged (PPOs) plans
long-term care insurance
refers to the broad range of medical and personal services for individuals (often the elderly) who need assistance with daily activities for an extended period of time
Skilled nursing care
Daily nursing care ordered by a doctor; often medically necessary. It can only be performed by or under the supervision of skilled medical professionals and is available hours a day.
Custodial Care
Level of health or medical care given to meet daily personal needs, such as dressing, bathing, getting out of bed, and so on. Though it does not require medical training, it must be administered under a physician's order.
home health care
Skilled or unskilled care provided in an individual's home, usually on a part-time basis.
Adult Day Care
Type of care (usually custodial) designed for individuals who require assistance with various activities of daily living, while their primary caregivers are absent. Offered in care centers.
respite care
A type of temporary health or medical care provided either by paid workers who come to the home or by a nursing facility where a patient stays to give a caregiver a short rest.
core benefit
All medicare supplement plans cover coinsurance on hospital costs, up to an additional 365 days after Medicare Part A hospital benefits run out
Long-term Care Partnership Programs
Federally- supported, state-operated initiative that allows individuals who purchase a qualified long term care insurance policy or coverage to protect a portion of their assets that they would typically need to spend down prior to qualifying for Medicaid coverage.
Continuing Care
Designed to provide a benefit for elderly individuals who live in a continuing care retirement community
private fee-for-service plan
Plan that allows patients to go to any Medicare-approved doctor or hospital that accepts Medicare payments. Decides how much it will pay and what the Medicare enrollee pays for the services renedered
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
a new formula for Medicare part B that is based on pay-for- performance program. Based on:
-Meaningful use
-Value based modifier based upon Physicians Quality Reporting System
-Value Based Modifier Cost
-Clinical Practice Improvement
Assisted Living
residences for people who do not need skilled, 24-hour care, but do require some help with daily care
Medicare supplement plan f and g
only Medicare supplement insurance plans that cover costs known as Medicare Part B excess charges.
excess charge
The difference between the Medicare approved amount for a service or supply and the actual charge.
Time Limit on Certain Defenses
states that after the policy has been in force for two years, the insurer cannot void the policy or deny a claim on the basis of misstatements in the application, except for fraudulent misstatements
Notice of Claim
A provision that spells out an insured's duty to provide the insurer with reasonable notice in the event of a loss. Typically 20 days or reasonably after
claim forms provision
the insurer is required to send the insured a claim form within 15 days after notice is received, asking for a payment on the terms of the policy. If the insurer fails do to so within said limit, the claimant may submit proof of loss in any form, explaining the occurrence, the character, and the extent of the loss for which the policy is submitted.
Proof of Loss
A statement of facts about a loss for which the insured is making a claim within days of the loss, usually 90
Time of Payment of Claims
Requires that claims be paid immediately, or within a stated number of days. If disability income payment is involved, they must be paid at least monthly if not at more frequent intervals.
Payment of Claims Provision
an insurance contract specifies how and to whom claim payments are made to. Payments for loss of life are to designated beneficiary. If no beneficiary has been named, it goes to the deceased estate. Claims on any thing other than death are paid to the insured or ANY OTHER NAMED PARTY (medical professional, hospital, etc.) Must not exceed $1000
Physical Exam and Autopsy provisions
allows an insurer, at its own expense, to have an insured physically examined when a claim is pending or to have an autopsy performed where not prohibited by law, during a reasonable period of time.
Legal Action provision
requires the insured to wait at least 60 days after proof of loss is submitted before legal action can be brought against the insurer
Change of Beneficiary
permits the insured to change the beneficiary as often as they'd like except when irrevocable
Other Insurance in this Insurer provision
total amount of coverage to be underwritten by a company for one person is restricted to a specified maximum account, regardless of the number of policies issued
Insurance With Other Insurers Provision
states the benefits payable for expenses incurred will be prorated in cases where the company accepted the risk without being notified of other existing coverage for the same risk. This is done in an attempt to deal with the potential problem of over insurance
Relation of Earnings provision
If disability income benefits from all disability income policies for the same loss exceed the insured's monthly earnings at the time of disability, this states that the insurer is liable only for that proportionate amount of benefits as the insureds earnings bear to the total benefits under all such coverage
Unpaid Premiums Provision
if there is an unpaid premium at the time a claim becomes payable, the amount of the premium is to be deducted from the sum payable to the insured or beneficiary; permits it from be taken from claim payments
Conformity with State Statute provision
Policy provisions must conform to state regulations where policy is sold.
Policy loan or Cash Value Provisions
found in whole life policies and some long-term care policies. Must begin to build cash value after a certain number of years. These loans, with interest, cannot exceed the guaranteed cash value or the policy is no longer in force. Not taxable. Any loans with interest due at the time of death will be deducted from the insureds policy proceeds
Return of Premium Rider
pays the total amount of premiums paid into the policy in addition to the face value, as long as the insured dies within a certain time period specified in the policy. It also returns premiums to the living insured at the end of a specified period of time, as long as the premiums have been paid.
Right of Assignment
most commercial health policies lets policyowners assign benefit payments from then insurer directly to the health care provider, relieving the policyowner of first having to pay the medical provider
12 mandatory policy provisions
entire contract, incontestability, grace period, reinstatement, notice of claim, claim forms, proof of loss, time of payment of claims, payment of claims, physical exam and autopsy, legal action, change of beneficiary
11 Optional Policy Provisions
Change of Occupation, Misstatement of Age, Other Insurance with this insurer, Insurance with other insurer, insurance with other insurers, relation of earnings to insurance- average earning clause, unpaid premiums, cancellation, conformity with state statutes, illegal occupation, intoxicants and narcotics
No Loss / No Gain
requires that when health insurance is replaced, ongoing claims under the former policy must continue to be paid under the new policy, thereby overriding any preexisting conditions exclusion
Double Indemnity
twice the regular benefit if an injury is sustained under certain specified conditions.
Adverse Selection
tendency of a disproportionate number of poor risks to seek or buy insurance or maintaining existing insurance in force( selection against company insurance) Sound underwriting reduces this
Age Change
The date halfway between birthdays when the age of the applicant changes to the next higher age. With some insurers, the age is based upon the applicant's age at his nearest birthday. In others, it is based upon the age of his last birthday.
Attending Physician's Statement (APS)
Designed to obtain more specific information about a particular medical problem revealed in the application or during the medical examination
Avocation
hobby in which some that are more scrutinized (skydiving) during the underwriting process, in the form of a special questionnaire. Fishing is not one of those hobbies
Binding Receipt (Unconditional)
Given by a company upon an applicant's first premium payment. The policy, if approved, becomes effective from the date of the receipt.
Claims Experience
Insureds history of claims or rates of loss. The greater -- the higher the required premium
Community Rating
insurance carriers generally base --- on their overall claim experience and healthcare costs in a geographical area
Conditional Receipt
when agents collect the initial premium with an application. Proof of payment and temporary guarantees of coverage as long as a specific condition is satisfied. Begin on specified date, whichever is later. Without this, no coverage is in force until the policy is issued, delivered and accepted with initial premium paid
Constructive Delivery
when an insurance carrier gives up all control of a policy and releases it for unconditional delivery to someone acting as the policyholder, including the company's own agent
Consumer Report
A report that may contain information regarding an individual's credit standing, character, reputation, personal characteristics, and mode of living.
Declined Risk
applicants who are rejected
Delivery Receipt
a form signed by a purchaser to show that goods were received. It can designate the start of the policy's free look period
Disclosure Form
must be provided to purchasers prior to making an offer in order to clarify exactly what is being sold and what is being purchased
Earned Premium
prorated amount of paid-in-advance premiums allocated to the portion of the policy term that has already elapsed
Expense Factor (Loading)
The insurers operating expenses into premiums; commissions, administrative costs, overhead, profit, and regulatory reserve
Field Underwriter
agent or producer completing the consumer's insurance application
Field Underwriting
producer determines the risks are desirable and submits those to the underwriting department for approval. The producer provides any required disclosure of information practices to an applicant, such as a notice regarding replacement, a buyers guide, an outline of coverage, or a policy summary
Health insurance premium
=morbidity- interest +expenses
Information and Privacy protection act
Each insurer must conform with state and federal laws privacy. This also prohibits insurers from basing their decisions solely on previous adverse underwriting decisions
Inspection Receipt
documents the temporary release of a new policy to the prospective policyholder without payment. It allows the prospective insured to review the contract before actually buying it.
Inspection Report
Report of an investigator providing facts required for a proper underwriting decision on applications for new insurance and reinstatements. Health, habits, finances and reputation
Interest
the income insurance companies earn from investing paid premium. assume an expected rate of return
Medical Information Bureau (MIB)
A service organization that collects medical data on life and health insurance applicants for member insurance companies.
Morbidity
the level of risk that someone has of suffering disability, usually within a given year, a given age, and as part of a defined population group
Non-medical
Refers to an application evaluated without a medical exam
Outline of Coverage
Describes the basic benefits, conditions, and other terms of an insurance policy without using industry jargon
Payor
one who pays the policy premium
Policy Fee
A small transaction fee charged by some insurers for the first or subsequent years of the life of an insurance policy, in addition to the regular premium.
Policy Term
The period of time for which a health insurance policy provides coverage.
Policyholder
the person who can exercise the rights or options conferred by the policy. Usually the payor as well
Rated Policy (Rating- up)
the basis for an additional charge to the standard premium because the person insured is classified as a higher than average risk. The above standard rates usually result from impaired health or hazardous occupations
Rated Up Premium
The additional amount added to the standard premium to account for the additional risk involved in underwriting a substandard loss exposure
Special Class
Applicants who cannot qualify for standard insurance but may secure policies with riders waiving payment for losses involving certain existing health impairments. The insurer may require the applicant to pay a higher premium or accept a policy other than the one for which he has applied
Trial Application
is one submitted without the initial premium. The policy would not take effect until the policy is issued by the insurer, delivered by the agent and the premium is paid.
Concurrent Review
A review of the health record while the patient is still hospitalized or under treatment
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