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81 Cards in this Set

  • Front
  • Back
"health and accident insurance," "accident and sicknessinsurance" and "health insurance" me":"
insurance that provides financial protection from the highcosts of illness and injury. Within the broad field of health insurance, thereare three distinct categories of health coverage:
Medical Expense Insurance e:
provides financial protection against the cost of medical care byreimbursing the insured, fully or in part, for these costs.
Disability Income Insurance
designed to provide a replacement income when wages are lost dueto a disability.
Accidental Death and Dismemberment Insurance
AD&D, is the purest form of accident insurance, providing theinsured with a lump-sum benefit amount in the event of accidental death ordismemberment
Group Health insurance
to members of a specified group. Group Health plans are available toemployers



trade and professional associations, labor unions, credit unions andother organizations

state and federal government programs

medicare


medicaid


oasdi diability

Health insurance

renewability provisions

l. Cancellable;

2. Optionallyrenewable


3. Conditionallyrenewable


4. Guaranteedrenewable


5. Noncancellable

Premium payment
including annual, semiannual, quarterly and monthly
Cost
formulas are complex and vary from insurer to insurer

If expenses and claims costs are higher than expected,the group policyowner may not qualify for a dividend or refund credit.rjq+U+

Reserves
set aside by an insurance company and designated for the payment offuture claims. Part of each premium isdesignated for the reserves
Premium reserves
reflect the liability of the insurer for losses that have not occurredbut for which premiums have been paid.va]��2Q0o
Reserves earmarked as loss (or claims) premiums
represent the insurer's liability for losses that have occurred, but forwhich settlement is not yet complete
Claims
Medical expense insurance, for example, is typically based on a contractof reimbursement meaning that the benefit an insured receives is not fixed, butinstead is dependent on the amount of the loss. Its purpose is to reimburse theinsured for the amount of loss sustained (within limits)
MedicalExpense Insurance
Provides benefits for the cost of medical care.
DisabilityIncome Insurance
Provides a specified periodic income to the insured, usuallyon a monthly basis, in the event he or she becomes disabled.
Accidental Death andDismembermentInsurance
Provides a lump sum payment in the event the insured dies due to anaccident or suffers the loss of one or more body members due to an accident.
A noncancelable, guaranteed renewable, or noncancelable and guaranteedrenewable policy
may not provide for termination of coverage of a spouse solely becauseof the occurrence of an event specified for termination of coverage of theinsured, other than nonpayment of premium
The terms noncancelable, guaranteed renewable or noncancelable andguaranteed renewable
may not be used without further explanatory language and may only beused in a policy which the insured has the right to continue in force by thetimely payment of premiums until the age of 65 or eligibility for Medicare
status-type military service exclusion
suspends coverage during military service
a family policy covering both husband and wife
the age of the younger spouse must be used as the basis for meeting theage and durational requirements
Policies providing convalescent or extended care benefits
may not condition such benefits upon admission to the convalescent or extendedcare facility within a period of less than 14 days after discharge from thehospital.
policy providing coverage for the recipient in a transplant operation
must also provide for the reimbursement of any medical expenses of alive donor to the extent that benefits remain
recurrent disabilities
recurrent disability be separated by a period greater than sixmonths from the last previous occurrence of thedisability.
Accidental death and dismemberment benefits
occurs within 90 days from the dateof the accident.
Each individual health insurance policy must include
a renewal, continuation or nonrenewable provision.
Policiesproviding convalescent or extended care benefits following hospitalization maynot condition such benefits upon admission to the convalescent or extended carefacility

14 days

Accidental death and dismemberment benefits
within 90 days
Entire Contract
means the policy itself
Time Limit on Certain Defenses
to limit the period of time in which an insurer may challenge thecontract or deny a claim on grounds of material misrepresentation
After two years have elapsed from the date the policy was issued
no material nondisclosures or misstatements (except fraudulentmisstatements) made by the applicant may be used to void the policy or deny aclaim after the time limit has expired
The insurer cannot deny a claim on the basis of
preexisting conditions afterexpiration of a two year time limit, unless the condition was excluded fromcoverage under the policy by name or specific description.
grace period

premiums are paid weekly

7 days
grace period

10 days

paid monthly
grace period

3 1 days

for all other modes of premium payment
Reinstatement
is automatic if the insurer or producing agent accepts the policypremium without requiring a completed application as a condition of policyreinstatement.
Notice of Claim
within 20 days
Claim Forms
15 days after notice
Proof of Loss
within 90 days
Legal Actions
- Must wait 60 days

, but not later than three years after proof of loss

Change of Occupation
change to a more hazardous occupation

change to a less hazardous occupation ~

Misstatement of Age
allows the insurer to adjust the benefit payable if the age of the insured was misstated
Illegal Occupation
is denied if injured while involved with an illegal occupation or activity
Relation of Earnings to Insurance -
will not receive more cash from disability insurance than he/she wouldwhile working.
Conformity With State Statutes
2. -Any provision which is in conflict with statutes of the state is automaticallyamended to meet state requirements.
Other Insurance With This Insurer -
Any amount of insurance in excess of astated amount shall be void and premiums paid will be returned to the insured.

Liability is limited to one policy selected by the insured and premiumsfor all others are refunded.

Unpaid Premium
allowsan insurer to deduct premiums that are due or past due as part of settling a claim.
Cancellation
insurer, within the first 90 days -
Insuring Clause
policy stipulating the conditions under which benefitsare to be paid for losses resulting from sickness or accident
Free Look Provision (Right to Return
policywithin 10 days of its delivery and to have the premium refunded if afterexamination of the policy the policyholder is not satisfied for any reason.
Medicare Supplements and Long Term Care

free look

30 day free look period
Consideration Clause
contract must give some valuableconsideration
Probationary Period
provision states that a period of time must lapse before coverage goesinto effect for specified conditions
Elimination Period
time deductible commonly found in disability income policies. It is aperiod of days which must expire after the onset of an illness or occurrence ofan accident before benefits will be payable. The longer the elimination period,the lower the cost of coverage
Waiver of Premium
that in the event of permanent and total disability, premiums will bewaived for the duration of the disability.
Preexisting Conditions
2. —Coverage usually does not apply to prior conditions for which the insuredreceived medical advice or treatment (or should have) within a certain numberof years before the date of application.
Recurrent Disability
specifies the period of time that must lapse between two illnesses inorder for a new set of benefits to be available for the second illness.
Coinsurance
sharing of expenses between the insured and the insurance company
Deductibles
specified dollar amount the insured pays before the insurance companywill pay policy benefits
Continuation of Coverage
only available to an employee or group member who has been continuouslyinsured under the group policy, or for similar benefits under any other grouppolicy that it replaced, during the three months immediately before termination
Hospital Service Corporation
- is a nonprofit, nonstock corporation,

20/80

Medical Service Corporation
is a nonprofit, non-stock corporation

20/80


licensed physicians, dentists and podiatrists for medical or surgicalservices and with licensed chiropractors and other health agencies

Travel Accident Insurance
death or injury resulting from accidents occurring while theinsured is a fare-paying passenger on a common carrier.
Specified Disease or Dread Disease Insurance
only certain diseases, usually cancer or heartdisease.
Hospital Income Insurance
daily, weekly or monthly basis while the insured is confined to a hospital.
Accident Only Insurance
coverage for injury from accident, and excludes sickness
Blanket Insurance
Often the individual's name is not known because the individuals comeand go. Such groups include students, campers, passengers of a common carrier,volunteer groups, and sports teams.

insureds cannot sue their insurers for payment under a health policy until

60 days


3 years

representations

statements made to the health insurance application

10 days

the free look provision

10 days

minimum number of days the grace period must contain before an accident

proof of loss

resposibility of an insured who is making a claim

timely of payment of claim

requires insurance company to pay claims promptly

benchmark health insurance coverage there is a penalty for failing to have a inpatient hospital admin precertified

500.00

all of these are optional provision except notice of claim

cancellation


conformity with state statute


intoxicants and narcotics

capitation

fixed amount paid by a health insurance maintenance orginization to a health care provider under contract with the health maintance organization in exchange for the rendering of health care services

20 days of loss

notice of claim required provision

26th day

coverage stops at the end of the month on this day...day of birthday

conformity of state law

automatically amend an existing policy to conform to state law should state law invalidate a policy provision

modified provision is not less favorable to the insured

a company may change the wording of a uniform policy provision in its health insurance policy

no more then 50 no fewer then 2

a small employer group is any person or firm etc who employed this average

the reinstatement provison in health insurance

allows the insured to reinstate the policy after coverage lapses