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81 Cards in this Set
- Front
- Back
"health and accident insurance," "accident and sicknessinsurance" and "health insurance" me":"
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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:
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Medical Expense Insurance e:
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provides financial protection against the cost of medical care byreimbursing the insured, fully or in part, for these costs.
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Disability Income Insurance
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designed to provide a replacement income when wages are lost dueto a disability.
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Accidental Death and Dismemberment Insurance
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AD&D, is the purest form of accident insurance, providing theinsured with a lump-sum benefit amount in the event of accidental death ordismemberment
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Group Health insurance
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to members of a specified group. Group Health plans are available toemployers
trade and professional associations, labor unions, credit unions andother organizations |
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state and federal government programs
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medicare medicaid oasdi diability |
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Health insurance
renewability provisions |
l. Cancellable;
2. Optionallyrenewable 3. Conditionallyrenewable 4. Guaranteedrenewable 5. Noncancellable |
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Premium payment
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including annual, semiannual, quarterly and monthly
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Cost
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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+ |
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Reserves
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set aside by an insurance company and designated for the payment offuture claims. Part of each premium isdesignated for the reserves
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Premium reserves
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reflect the liability of the insurer for losses that have not occurredbut for which premiums have been paid.va]��2Q0o
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Reserves earmarked as loss (or claims) premiums
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represent the insurer's liability for losses that have occurred, but forwhich settlement is not yet complete
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Claims
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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)
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MedicalExpense Insurance
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Provides benefits for the cost of medical care.
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DisabilityIncome Insurance
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Provides a specified periodic income to the insured, usuallyon a monthly basis, in the event he or she becomes disabled.
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Accidental Death andDismembermentInsurance
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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.
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A noncancelable, guaranteed renewable, or noncancelable and guaranteedrenewable policy
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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
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The terms noncancelable, guaranteed renewable or noncancelable andguaranteed renewable
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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
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status-type military service exclusion
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suspends coverage during military service
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a family policy covering both husband and wife
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the age of the younger spouse must be used as the basis for meeting theage and durational requirements
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Policies providing convalescent or extended care benefits
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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.
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policy providing coverage for the recipient in a transplant operation
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must also provide for the reimbursement of any medical expenses of alive donor to the extent that benefits remain
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recurrent disabilities
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recurrent disability be separated by a period greater than sixmonths from the last previous occurrence of thedisability.
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Accidental death and dismemberment benefits
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occurs within 90 days from the dateof the accident.
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Each individual health insurance policy must include
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a renewal, continuation or nonrenewable provision.
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Policiesproviding convalescent or extended care benefits following hospitalization maynot condition such benefits upon admission to the convalescent or extended carefacility
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14 days |
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Accidental death and dismemberment benefits
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within 90 days
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Entire Contract
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means the policy itself
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Time Limit on Certain Defenses
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to limit the period of time in which an insurer may challenge thecontract or deny a claim on grounds of material misrepresentation
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After two years have elapsed from the date the policy was issued
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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
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The insurer cannot deny a claim on the basis of
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preexisting conditions afterexpiration of a two year time limit, unless the condition was excluded fromcoverage under the policy by name or specific description.
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grace period
premiums are paid weekly |
7 days
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grace period
10 days |
paid monthly
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grace period
3 1 days |
for all other modes of premium payment
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Reinstatement
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is automatic if the insurer or producing agent accepts the policypremium without requiring a completed application as a condition of policyreinstatement.
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Notice of Claim
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within 20 days
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Claim Forms
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15 days after notice
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Proof of Loss
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within 90 days
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Legal Actions
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- Must wait 60 days
, but not later than three years after proof of loss |
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Change of Occupation
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change to a more hazardous occupation
change to a less hazardous occupation ~ |
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Misstatement of Age
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allows the insurer to adjust the benefit payable if the age of the insured was misstated
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Illegal Occupation
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is denied if injured while involved with an illegal occupation or activity
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Relation of Earnings to Insurance -
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will not receive more cash from disability insurance than he/she wouldwhile working.
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Conformity With State Statutes
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2. -Any provision which is in conflict with statutes of the state is automaticallyamended to meet state requirements.
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Other Insurance With This Insurer -
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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. |
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Unpaid Premium
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allowsan insurer to deduct premiums that are due or past due as part of settling a claim.
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Cancellation
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insurer, within the first 90 days -
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Insuring Clause
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policy stipulating the conditions under which benefitsare to be paid for losses resulting from sickness or accident
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Free Look Provision (Right to Return
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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.
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Medicare Supplements and Long Term Care
free look |
30 day free look period
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Consideration Clause
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contract must give some valuableconsideration
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Probationary Period
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provision states that a period of time must lapse before coverage goesinto effect for specified conditions
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Elimination Period
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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
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Waiver of Premium
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that in the event of permanent and total disability, premiums will bewaived for the duration of the disability.
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Preexisting Conditions
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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.
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Recurrent Disability
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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.
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Coinsurance
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sharing of expenses between the insured and the insurance company
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Deductibles
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specified dollar amount the insured pays before the insurance companywill pay policy benefits
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Continuation of Coverage
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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
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Hospital Service Corporation
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- is a nonprofit, nonstock corporation,
20/80 |
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Medical Service Corporation
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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 |
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Travel Accident Insurance
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death or injury resulting from accidents occurring while theinsured is a fare-paying passenger on a common carrier.
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Specified Disease or Dread Disease Insurance
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only certain diseases, usually cancer or heartdisease.
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Hospital Income Insurance
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daily, weekly or monthly basis while the insured is confined to a hospital.
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Accident Only Insurance
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coverage for injury from accident, and excludes sickness
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Blanket Insurance
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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.
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insureds cannot sue their insurers for payment under a health policy until |
60 days 3 years |
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representations |
statements made to the health insurance application |
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10 days |
the free look provision |
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10 days |
minimum number of days the grace period must contain before an accident |
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proof of loss |
resposibility of an insured who is making a claim |
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timely of payment of claim |
requires insurance company to pay claims promptly |
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benchmark health insurance coverage there is a penalty for failing to have a inpatient hospital admin precertified |
500.00 |
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all of these are optional provision except notice of claim |
cancellation conformity with state statute intoxicants and narcotics |
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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 |
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20 days of loss |
notice of claim required provision |
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26th day |
coverage stops at the end of the month on this day...day of birthday |
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conformity of state law |
automatically amend an existing policy to conform to state law should state law invalidate a policy provision |
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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 |
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no more then 50 no fewer then 2 |
a small employer group is any person or firm etc who employed this average |
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the reinstatement provison in health insurance |
allows the insured to reinstate the policy after coverage lapses |