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27 Cards in this Set
- Front
- Back
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Probation Period |
Coverage begins not more than 30 days from date of policy issue; reduces risk of claim from existing condition. Insurer chooses length of time at new policy issue. |
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Individual Policy Premium Rating Factors |
Age Gender (not used in accident insurance) Occupation (not used in health insurance) Physical Condition Moral Hazards |
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Community Rating |
Cost of medical services in insured's community |
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Group Policy Rating Factors |
Male to Female Ratio Average Group Age Amount of Benefits |
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Experience Rating |
# of claims in a particular risk class |
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Replacement of Health Insurance |
Agents must provide a transfer of benefits statement that assures old benefits will continue under new plan New policy must continue to pay ongoing claims under former policy |
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HMO Exclusions |
Eye exams for adults Dental Out of area benefits unless emergency Seeking treatment around primary care doc |
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Open vs. Closed Panel |
Closed only provides service to HMO members (ex. Kaiser) |
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HMO Models |
Group Practice: open or closed Staff: closed Independent Practice Assoc: open or closed |
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Blue Cross/Blue Shield |
BC: hospital coverage BS: medical coverage Typically pay directly to provider, e.g. on a service basis |
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State Mandated Benefits |
Alcohol Mental Prenatal/natal Prostate if over 45 Newborns or adopted kids: 31 days to notify Immunizations (no copay) for 72 months |
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Elimination Period |
Period before benefits begin, e.g. a time deductible. Reduces claims for minor injuries. Insured chooses this period (longer period will reduce cost). |
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Pre-existing Exclusionary Period |
Max 2 years. Insurer chooses. On new policy issue only. |
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Cancellable |
5 days notice |
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Optionally Renewable |
Insurer can terminate at policy renewal date or premium payment date |
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Conditionally Renewable |
Insured may renew at stated dates Insurer can decline if all other policies in same risk class aren't renewed |
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Period of Time Renewal |
Buy a new policy when current policy expires. Used with temporary health or accident policies |
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Guaranteed Renewal, Adjustable Premium |
Insurer must renew, but can increase rates Rate increases must be across the entire risk class |
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Non-Cancellable / Guaranteed Renewal with Guaranteed Premium |
No premium adjustment unless stated in schedule included in the policy |
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Health Insurance Grace Period |
7 days for weekly premiums 10 days for monthly 31 days for all other |
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Notice of Claim |
Insured must submit claim within 20 days or ASAP |
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Claim Forms |
Insurer has 15 days to provide claim form to insured If insurer fails to deliver, insured can submit on regular paper |
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Proof of Loss |
Insured must submit proof within 90 days or a reasonable time (not more than 1 year) |
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Time of Payment Claims |
Insurer must pay claim immediately upon proof of loss |
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Legal Action |
No suit can be filed before 60 days after filing proof of loss |
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Relation of Earnings to Insurance |
Once disability payments exceeds earned income, benefits are reduced proportionally and excess premiums are refunded. |
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Case Management Provision |
Requires submission of claim info before treatment (basically pre-authorization) |
