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266 Cards in this Set
- Front
- Back
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Which of the following concepts is founded on the ability to predict the approximate number of deaths or frequency of disabilities within a certain group during a specific time?
a. Principle of large loss b. Quantum insurance principle c. Indemnity Law d. Law of large numbers |
d. law of large numbers
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The owner of a camera store is worried that her new employees may help themselves to items from inventory without paying for them. What kind of hazard is described?
a. Physical hazard b. Ethical hazard c. Morale hazard d. Moral hazard |
d. moral hazard
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All of the following actions are examples of risk avoidance EXCEPT?
a. Bill won't fly in an airplane b. Wemdu keeps her money out of the stock market c. Pat pays his insurance premium d. John never drives a car |
c. Pat pays his insurance premium
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Risk Avoidance
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One method of dealing with risk is risk avoidance, simply avoiding as many risks as possible. By choosing not to drive or own an automobile, one could avoid the risk associated with driving. By never flying one could eliminate the risk of being in an airplane crash. By never investing in stock, one could avoid the risk of a market crash. Clearly risk avoidance is effective, but it is not always practical. Few risks can be handled in this manner
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Eligible employees or their dependents may not be denied coverage under a group health plan or insurance policy due to
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health status; medical condition; claims and exerience; receipt of health care; medical history; genetic information; evidence of insurability-including arising from acts of domestic violence; disability
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Under the law group health plans and insurers can only apply preexisting exclusing to
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late entrants; person who has never had health coverage; person who have previously hasd health coverage for less than 63 days; a person who has been without coverage for more than 63 days
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A late entrant is a plan member or a dependant who does not enroll during
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the first period in which she/he is eligible to enroll; or; a special enrollment period when there is a change in family status or loss of group coverage under another plan;
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Preexisting exclusiions are not allowed for
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mewborns; adopted children placed for adoption; pregnancy (including late term)
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Standard and Alternative Methods of Counting Credible Coverage
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Mental health; substance abuse treatment; prescription drugs; dental care; vision care
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Special Enrollment Periods
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Group health plans and insurers must offer special enrollment periods during which eligible persons are allowed on the plan without being considered late entrants. Eligible employees or dependents are allowed to enroll within 30 days following:
separation; divorce; death; termination of employment; reduction in work hours; employers contributions toward coverage have terminated; exhausion of Cobra contrinuation or state continuation |
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A change in family status due to
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marriage; birth of a child; adoption or placement for adoption of a child
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Can employee or dependent spouse enroll in plan during special enrollment period?
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yes: Employees and dependent spouses who are other wise eligible but not enrolled in the plan; can also enroll during the special enrollment period when a change in family status occurs. Persons enrolling under these special enrollment conditions cannot be treated as late entrants
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If someone loses other coverage when are the eligible to enroll?
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For persons losing other group coverage; special enrollement requests can be made only after losing eligility for the other coverage. Special enrollment is not available in the previous coverage loss resulted from fraudulent activity; or because the person did not pay premiums.
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An insurer my renew insured group policies at the employers options except for
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non payment of premiums; fraud; violations of participation or contribution rules and insurance carrie may set its own participation or contribution rules; so long as they comply with state law; termination of coverage the carrier ceases to offer coverage in a particulation market; movement outside the service area (applies to networks); for associatio plans; of an employer's membership in th association ends. Under certain circumstances, however, an insurer may modify coverage. Am insurer may also discontinue some or all of coverage's in certain markets. If this is done, group health plans and state insurance departments must be notified in advance
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Guranteed renewable clause
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prohibits the cancelation of a policy as long as the premiums are paid properly and no false information has been supplied in order to obtain coverage. Providing false information can have much more serious consequences that just losing insurance coverage it is a crime
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How many years can an insurance company go back in Florida regarding preexisting conditions?
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The preexisting law for Florida health insurance is not as stringent as in some states. Two year sis as far bas at the insurance company can go to determine preexisting conditions. Some states allow five years and some even has as many as indefinate limit. In Florid, if you have sought treatmetn for or were diagnosed with any condition it is considered to be existing. I fyou maintain contiuous coverage and switch policies the preexisting condition restriction can be covered the length of time your previous plan was in existence.
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Who licenses insurance companies in Florida?
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The state of Florida licenses all insurance companies in Florida. If you live in Florida and you contact an insurance company that is licensed by the state, you should not do business with that company. Florida maintains records of all complaints and problemes encountered with the various companies. To determine if a company is in good standing, contact the state department of insurance
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Can carriers in Florida refuse to offer a policy based on health issues?
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Florida health insurance carriers can refuise to offer a policy based on health issues. Premium can be determined by the status o your health, age, and contributin factors. The regulations regarding the option to offer or deny coverage very in lenient in Florida. If your are health it a good time to obtain health insurance coverage
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Cobra-Consolidated Omnibus ou Budget Reconcilation Act
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Terminated employees or those that lose medical coverage because of reduced work hoursmay be able to buy group coverage for themselves and their families for limited periods of time. If you are entitled to Cobra benefits, your health plan mus give you a notice stating your rights to choose to continue benefits provided by the plan. You have 60 days to accept the coverage or lose all rights to benefits. Once Cobra coverage is chosen, you are required to pay for coverage. Replaces ERISA the Internal Revenue Code and Public Health Service Act
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When would a dependent child be qualified for Cobra?
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Termination of covered employee's employment for any reason by gross misconduct; Reduction in the hours worked by the covered employee; Loss of dependent child status under plan rules; Covered employee's becoming entitled to Medicare; divorce or legal separation of the covered employee; death of the covered employee
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Cost for Cobra can not exceed
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102 percent of the cost of the plan for similarly situated individuals
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Payment for Cobra must be made within how many days of election?
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45 days
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HMO
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Health Maintenace Organization
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Traditional Indemnity Plan
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Fee for service
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PPO
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Prefered Provider Organization
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POS
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Point of Service Plan
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Types of Group Plans you commonly see in Florida
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HMOs, PPO's, POS, Fee for Service or traditional indemnity plans
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Preferred Provider Organization
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Have made arrangemetns for lower fees within networkof health care providers. PPOs give their policy holders a financial incentive to stay within the network
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Point of Sevice
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They introduce the gatekeeper or Primary Care Physician. You will need to choose your pCP from among the plans network doctors. You can choose to go out of the network and still get some kind of coverage. In order to get a referral to a specialist you usually must go through your Primary Care Physician (PCP) You will have more hassles and more money out of pocket.
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Health Maintenance Organizations
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Most of the time you are talking about closed panel HMOs; the least expensive but least flexible type of health plan. They also tend to be geared more towards members of group plans than individuals.
In exchange for a low copayment low premiums and minimal paperwork, and HMO requires that you only see its doctors. and that you get a referral from you physician before you see a specialist. If you can still pick up the phone, you'll probally need to get clearance before you can visit the emergency room. An HMO may have central medical offices or clinics, or it may consist of a network of individual practices. In general you must see HUM approved physicians or pay the entire cost of the visit your self. HMOs have the best reputation for covering preventive services and health improvement programs |
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Types of Health Insurance Available
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Comprensive Major Medical; Catastrophic major medical; health savings account program; short term medical policies; medical supplement insurance; student health insurance; hospitalization
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indivdual supplemetnal insurance products
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accident plans; cancer; dental; hospitalization
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Senior Programs
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medicare supplements; longterm care; home health; life insurance for senior
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conversion policy
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If you have had atlest three months of coverage under afully insured group health plan from thecompany that provided you coverage. This is called the coversion policy face a new preexisting condition under the policy.
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If you are HIPAA eligible but do or a not qualify for a conversion policy. You are guranteed the right to an individual health policy from an insurance company that sells such a plan in Florida. Insurers that sell individual health insurance must offer you a choice of at least two pol
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HIPPA eligible
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GUrantee Issue Policy
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If your individual health or insurer or HMO terminated your coverage due to insolvency, dropped to all individual coverage in Florida or if you moved out of the individual health insurers service area.
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Gurantee Issue
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If you are a small employer buying a group health plan, you cannot be turned down because of the health status, age, or any factor that might predict the use of health services, of thouse in your group.
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Medicaid
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If you have modest or low household income, you may be eligible for free or subsidized health coverage for yourself or member of your family, The Florida Medicaid program offers free health coverage for pregnant women, families iwth children and elderly, and disabled individuals with low incomes. In addition some women who are diagnosed with Breast and cervical cancer may be eligible for medical care through Medicaid
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Trade Adjustment Assistance (TAA)
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If you have lost your health insurance and are receiving benefits from the Trade Adjustment Assistance program you may be eligilbe for federal income tax credit to help pay for health coverage. This credit is called the Health Coverage Tax Credit and it is equal to 65 % of the cost of qualified health coverage, including cobra stat contiuation coverage and a specific policy offered through Blue Cross Blue Shield of Florida
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Disabled child covered
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In Florida your disabled child can be covered as a dependant under your group health plan into adulthood. This applied if you dependant was already disabled and covered under the health plan before he or she reached the limiting agefor dependant coverage. You will be required to submit proof of your child's continued incapacity and dependency with 31 days following the date that your child reached the limiting age and annually thereafter. Subsequently if you change health plans you might not be able to your disabled son or daughter as a dependant under the new health plan
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Family Medical Leave Act
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If you have to take leave from your job due to illness, the birth or adoption of a child or to care for a seriously ill family member, you may be able to keep group coverage for a limited time. Federal law known as the Family and Medical leave Act (FMLA) gurantees you up to 12 weeks of job protection leae in these circumstances. The FMLA applies to you if you wore at a company with 50 or more employees
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If you do not return to work your employer may--regarding FMLA
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require you to pay back you share of health benefit/insurance premium. If you do not return to work because of factors outside your control such as a need to care for a sick family member, or because your spouse is transferred to a job in a distance city, you will not be required to repay the premium
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Look back period
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Group health plan can count a preexisting condition only those that your receved a diagnosis, treatmetn or medical advice within 6 months imediately before you joinede the plan. This period is called the look back period
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What can't a group plan apply an exclusion period
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pregnancy, newborns, or newly adopted children, children placed for adoption or genetic information
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How long can a preexisting condition be excluded?
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Under group health plan preexisting conditions can be excluded only for a limited time. The maximum period is 12 months. You will receive credit toward your preexisting condition exclusion period for any previous continous coverage
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If you enroll late in your group plan you may have a longer preexisting condition exclusion period of ?
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18 months. If you enroll late or as a late enrollee you may have a 18 month preexisitng condition exclusion period
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What is credible coverage?
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Federal Employee Health Benefits; Group health plan (COBRA); Military Health Coverage (Champus and Tricare); Indian Health Service; Individual Health Insurance; State Health Insurance High Risk Pools, Medicaid
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Speculative Risk
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A type of risk that involves the chance of both loss and gain not insurable
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Pure Risk
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Type of risk that involves the chance of loss only; there is no opportunity for gain, insurable
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Proof of loss
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a mandatory health insurance provision stating that insured must provide a completed claim form to the insurer within 90 days of the date of loss
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probationary period
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specified number of days after and insurance policy's issued date during which coverage is not afforded for sickness. Standard for group coverage is 10 days.
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Proper solicitation
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High professional standards that require an agent to identify himself properloy that is an agent soliciting insurance on behalf of an insurance company
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rebating
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returnign part of the commisson of giving anything else of value to the insured as an inducementh to buy the policy. It is illegal and can cause for license revocation in most states. In some states it is an offense by both the agent and the person receiving the rebate.
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reimbursement approach
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payment of health policy benefits to insured based o actual medical expenses incurred.
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reinstatement
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putting a lapsed policy bakc into force by producing satisfactoryh evidence of insurability and paying any past due premiums required
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representation
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statements made by application on their application for insurance that they represent as being substantially tru to the best of their knowledge and belief,but that are warranted as exact in eery detail
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reserve
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funds by the company to help fulfill future claims
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reserve basis
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refers to mortality table and assumed interest rate used in computing rates
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residual disability benefit
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a disabilty income payment based on the portion of income that the insured actually lost, taking into account the fact that he or she is able to earn some income
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respite care
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type of health or medical care designed to provide a short rest period for a caregiverl. Characterized by its temporary status.
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risk pooling
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a basic principle of insurance whereby a large number contribute to cover the losses of a few
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risk selection
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the method of a home office underwriter used to choose applicants that the insurance company will accept;. the underwrite must determine whether the risks are standard, substandard or preferred and adjust the premium accordingly
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hazard
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any factor that gives rise to peril
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Health Care and Insurance Reform Act
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this 1993 act establishes a new model for health care delivery in Florida called managed care
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health insurance
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insurance against loss through sickness or accidental bodily injury also called accident and health, accident and sickness and sickness accident or disability insurance
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Health Maintenance Organization (HMO)
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Health care management stressing preventive halth care, ealry diagnosis and treatmenton an outpatient basis. Persons generally enroll voluntarily by paying a fixed fee periodically.
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home health care
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skilled or unskilled care provided in an individual's home, usually on a partime basis
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home service insurer
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insurer that offers relatively small policies with premiums payable on a weekly basis, collected by agents at the policyowners home.
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Hospital benefits
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payable for charges incurred while the insured is confined to or treated in a hospital, as defined in health insurance policy
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hospital expense insurance
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health insurance benefits subject to a specified daily maximum for a specified period of time while injured is confined to a hospital, plus a limited allowance up to a specified amount for miscellaneous hospital expenses, such as operatiing room, anesthesia, laboratory fees, and so on.
Also called hospitalization isnurance |
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hospital indemnity
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form of health insurance providing a stipulated daily, weekly or monthly indeminty during hospital conrfinement payable on an unallocated basis without regard to actual hospital expense.
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indidual insurance
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policies providing protection ot the policy owner, as distict from group and blanket insurance. Also called person insurance
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insurability
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all conditions pertaining to individuals that affect their health, susceptibility to injury or life expectancy, and indviduals risk profile
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insurability receipt
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a type of conditional reciept that makes coverage effective on the date of the application was signed or the date the medical exam was provided that appliatin proved to be insurable
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insurable interest
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requirement of insurance contracts that loss must be sustained by tghe applicant upon the death of disability of another and loss must be sufficent to warrant compensation
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insurance
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is the social device for minimizing risk of uncertainty regarding loss by spreading the risk over a large enough number of similar exposures to predict the individual chance of loss
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insurance code
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the laws that govern the business of insurance in a given state
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peril
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is the immediate specific event causing loss and giving rise to risk
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parole evidence
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rule of contract law that brings all verbal statements into the written contract and disallows any changes or modifications to the contract by oral evidence
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Partial disability
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illness or injury preventing the insured from performing at least one or more but not all tof the occupational duties
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participating physician
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a doctor or physican who accept Medicare's allowable or recognized charges and wil not charge more thatn this amount
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personal producing general agency system (PPGA)
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A methos of marketing selling and distributing insuranc ein which personal producing general agents are compensated for business they personally sell and business sold by agents with whom they subcontract. Subcontracted agents are considered employees of PPGA not insurer
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policy
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in insurance the written instrument in which a contract of insurance is set forth
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policy provisions
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the term or conditions of an insurance polciy as contained in the policy clause
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portability
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provision under the Florida Health Care Access Act in which workers or dependent will have to meet the waiting period for an existing condition
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precertification
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the insurer's approval od an insured's emtering a hospital. Many health policies require precertificationh as part of an effort to control costs
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preexisting condition
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an illness or medical condition that existed before a policy's effective date; usually excluede from coverage through the policy's standard provisions or by waiver
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prefered provider organzition
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Associaton of health providers, such as doctors and hospitals, that agree to provide health care to members of a particular group at fees negotiated in advance
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preferred risks
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a risk whose phsical conditions, occupation, mode of living, and other characteristics indicate a prospect for longevity for unimpaired lives of the same age
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premium
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the periodic payment requirement to keep an insurance policy in force
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premium factors
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the three primary factors considered when computing the basic premium for insurance is mortality,expense and interest
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prescription durg coverage
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usually offered as an optional benefit that provides medical expense plans this coverage covers some or all of the costs of prescriptions
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presumptive disability benefit
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a disability income policy benefit that provides that is and insured experiences a specified disability, such as blindness her or she is presumed to be totally disabled and entitle dto full amount under the policy, whether or not he or she is able to work
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primary insurance amount(PIA)
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amount equal to a covered worker's full social security retirement benefit at age 65 or disability benefit
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principal sum
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the amount under and Ad&D policy that is payable as a death benefit if death is due to an accident
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probationary period
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specified number of days after and insurance policy's issue datee during which coverage not afforded illness or sickness. Standard practice for group coverage
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proof of loss
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a mandatory health insurance provision stating that the insured must provide a completed claim form to the insurer within 90 days of the date of the loss
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proper solicitation
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high professional standards that require and agetn to identify himself of herself properly that is and agent soliting insurance on behalf of an insurance company
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reasonable and customary charge
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charge for health care sesrvcie consistent with the going rate of charge ina given geographical area for identical or similar services
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reciprocal insurer
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insurance company characterised by the fact its policy holders insure teh risk of other policy holders
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recurrent disability provision
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a disabilty income policy provision that specifies the periof of time during which reoccurence of a disability is considered a continuation of the prior disability
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reimbursement approach
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payment of health polcy benefits to insured based on the actual medical expensesw incurred
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reinstatement
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putting a lapsed policy back in force by producing satifactory evidence of insurability and paying the past due premium required
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reinsurance
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acceptance by one or more insurers called reinsurers of a portion of the risk underwritten by antoher insurer who has contracted for the entire coverage
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relative value scale
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method of determining benefits payable under a basic surgical expense policy. Points are assigned to each surgical procedure and a dollar amount per point or conversion factor, is used to determine the benefits.
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renewable term
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some term policies prove that they may be renewed on the same plan for one or more years without medical examination, but with rates based on the insureds advanced age
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representation
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statemetns made by applicants on their application for insurance that they represent as being substantially tru to the best of their knowledge and belief but that are not warranted as exact in every detail
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admitted insurer
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an insurance company that has met the legal and financial requirements for operation within a given state
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adverse selection
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against the company Tendency of less favorable insurance risks to seek or continue insurance to a greater extent than others. Also, tendency of policy owners to take advantage of favorable options in insurance contract
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aleatory
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feature of insurance contracts in that there ins an element of chance for both parties taht the dollar given by the policy holder premiums and the insurer benefits may not be equal
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alien insurer
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company incorporated or organzied under th laws of any foreign nation, providence or territory
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ambulatory surgery
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surgery performed on an outpatient basis
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any occupation
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a definition of total disability that requires that for disability income benefits to be payable the insured must be unable to perform any job for which he or she is reasonably suited by reason of education, training or experience
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basic medical expense policy
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health insurnce policy that provides first dollar benefits for specified and limited health care. such as hospitalization, surgery or physician services. Characterized by limited benefit period and relatively low coverage limits.
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benefit period
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maximum length of time that insurance benefits will be paid for any one accident, illness or hospitalization
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blanket policy
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covers a number of individuals who are exposed to the same hazards, such as members of an athletic team, company officials who are passengers in the same company plane and so on
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business continuation plan
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arrangements between business owners that provide that the shares owned by any one of them who dies or becomes disabled shall be sold to and purchased by the other coowners or by the business
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business health insurance
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issued primarily to indemnify a busines for he loss of services of a key employee, partner or actie close corpation stockholder
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business overhead expense insurance
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a form of disability income coverage designed to pay necessary business expenses, such as rent, should the insured business owner become disabled
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cafeteria plan
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employee benefis arrangments in which employees can select from a range of benefits
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cancelable contract
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health insurance contract that may be terminated by the company or that is renewable at its option
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capital sum
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amount provided for accidental dismemberment or loss of eyesight. Indemnities for loss of one one member or sight or one eyue are percentagesof the capital sum
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churning
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the practice by which policy values in an existing life policy or annuity contract are used to purchase another policy or contract with the same insurere for the purpose or earning additional premiums or commisions with out objectively reasonable basis for believing that the new policy will result in actual and demonstrate benefit
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closed panel HMO
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a group of physicians who are salaried employees of an hmo AND WHO WORK IN FACILITIES PROVIDED BY THE HMO
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COBRA
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Consolidated Omibus Budge Reconciliation Act of 1985-extending groups health coverage to terminated employees and their families for up to 18 to 36 months
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commercial health insurers
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insurance companies that function on the reimbursemetn approach which allows policy owners to seek medical treatmetn then submit the charges to the insurer for reimbursement
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commissioner
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head of the insurance department public officer charged with supervising the insurance laws. Called superintendent in some states director in other
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comprehensive major medical insurance
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designed to give protection offered by both a basic medical expense and major medical policy. It is charaterized by a low deductible amount coinsurane clause and high maximum benefit
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conditionally renewable contract
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insurance policy providing that the insure may renew the contract from period to period or continue it to a stated date or an advanced age subjectg to the right of insurer to decline renewal onloy under conditions defined in the contract
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conditioned receipt
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given to the policy owner when they pay a premium at tim eof application. Such receipts bind the insurance company if the risk is approvewd as applief for subject to any other conditions stated on the receipt
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corridor deductible
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in superimposed major medical plan a deductible amount between the benefits paid by the basic plan and the beginning of the major medical benefits
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cost of living rider
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a rider available with some policies that provides for automatic increase in benefits typically tied to Consumer price index offsetting the effects of inflation
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credit accident and health insurance
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if the insured debtor becomes totally disabled due to an accident or sickness the policy premiums are paid during the period of the disability or the loan is paid off. May be individual or group policy
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credit report
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a summary of an insurance applicatnts credit history made by an independent organization that has investigated the applicants credit standing
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custodial care
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level of health or medical care give 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
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delayed disability provision
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a disability income policy provision that allows a certain amount of itme after an accident for a disability to result and the insured remains elibilbe for benefits
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dental insurance
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a relatively new form of health insurance coverage typically offered on a group basis, it covers the cost of normal dental maintenance as well as oral surgery and root canal therapy
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disability
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physical or mental impairment making a person incapable of performing one or more duties of his or her occupation
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disability buy sell agreement
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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 coowners or the by business using funds from disability income insurance
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disability income insurance
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a type of health insurance coverage, it provides for the payment of regualr periodic income should the insured become disabled from illnes or injury.
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domestic insurer
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company within the state in whic it is chartered and in which its ome office is located
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dreaded disease policy
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limited risk policy
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elimination period
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duration of time between the begining of an insured's disability and the commencement of the period for which benefits are payable
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employee benefit plan
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plans through which employeers offer employees benefits such as coverage for medical expenses, disability, retirement and death.
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major medical expense policy
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health insurance policy that provides broad coverage and high benefits for hospitalization, surgery and physician servicees. Characterized by deductibles and coinsurance cost sharing
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managed card
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a system of delivering health care services, charcaterized by arrangements with selected providers, program of ongoing quality control and utilization review and financial incentives for members to use providers and procedures covered by the plan
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mandatory second opininon
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to control costs many health policies provide that in order to be eligible for benefits insureds must get a second opionion before receiving non life threatening surgery
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McCarran Feguson Act
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also know as a public law 15 the 1945 act exempting insurance from federal anti trust laws to the extent insurance is regulated by the states
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Medicaid
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provides medical care for the needed under joint federal state participation
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mecidal cost management
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the process of controlling how policy holders utilzie their policies
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medical examination
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usually conducted by a licensed physician the medical repotr is part of the applicatin becomes part of the policy contract and is attached to the policy. A non medical is a short form medical report filled out by the agent. various company rules such as amount of insurance applied for or already in force, or applicants age, sex, past physicial history and data revealed by inspection report, and so on determine whether the examination will be medical or non medical
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medical expense insurance
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pays benefits for non surgical doctors' fees commonnly rendered in a hospital sometimes palys for home and office calls
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Medical information Bureau
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a servcie organization that collects medical data on life and health insurance applicants for member insuance companies
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medical report
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a documetn completed by a physician or other approved exdaminer and submitted to ana insurer to supply medical evidence or insurabiity or lack of insurability or in relation to a claim
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Medicare
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Federally sponsored health insurance and medical program for persons 65 or older, administered under provisions of the Social Security Act
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Medicare Part A
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Compulsory hospitalizatin insurance that providees specified in hospitalization and related benefits. All workers covered by Social Security finance is operation through a portion of
FICA tax |
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Medicare Part B
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Voluntary program designed to provide supplementaryh medical insurance to cover physician services, medical services ad supplies not covered by Medicare Part A
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Medicare Part
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Medicare Part
C is called Medicare Advantage . This program offers a variety of managed care plans and private fee for for service plan, and Medicare specialty plans. These specialty plans provide services that focus care on the management of a specific disease or condition |
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Medicare Part D
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A program that offers a prescription drug benefit to help Medicare beneficiaries pay for the drugs they need. Teh drug benefit benefit is optional and is available to anyone whoe is entitled to Medicare Part A or enrolled in Part B This benefit is available through private prescription drug plans or Medicare Advantage plans
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Medicare supplement policy
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Health insurance that provides coverage to fill the gaps in Medicare coverage
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minimum premium plan (MPP)
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Designed to support a self insured plan, a minimum premium plan helps insure against large unpredictable losses that exceed the self insured level
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miscellaneous expense
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Hospitaol charges, other than for room and board drugs, laboratory fees, etc in connection with health insurance
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misrepresentation
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Act of making issuing circulating or causing to be issued or circulated an estimate, illustration, circular o statement of any kind that does not represent the correct policy terms, dividends or share of surplus or the name or title or any policy or class of policies that doesn to in fact reflect its true nature
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mistatement or age or sex provision
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If the insured's age or sex is misstated in an application for insurance, the benefit payable usually is adjusted to what he premiums paid should have purchased
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misuse of premiums
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Improper use of premiums collected by an insurance producer
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moral hazard
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Effect of personal reputation character, associates personal living habits financial responsibility and enviroment as distinguised from physical health upon an individual's general insurabiltiy
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morale hazard
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hazard arising from indifference to loss because of the existence of insurance
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morbidity
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the realtie incidence of disability due to sickness or accident within a given group
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morbidity rate
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shows the incidence and extent of disability that may be expected from a given large group of persons used in computing health insurance rates
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mortality
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the realtieve incidence of death within a group
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mortalitiy table
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listing of teh mortality experience of individuals by age, permits an actuary to calcuate on the average how long a male or femaile of a given age group may be expected to live
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multiple employer trust(MET)
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Several small groups of individuals that need life and health insurance but do not quality for a true group insurance band together under state trust laws to purchase insurance at a more favorable rate
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Multiple Employers Welfare Arrangement (MEWA)
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Similar to a multiple emplyer trust with the exceptiob that in a MEWA a number of employers pool their risk and self insure
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National Association of Underwriters
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is an organizaton of health insurance agents that is dedicated to supporting the health insurance industry and to advancing the qualtiy of service provided by insurance professionals
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National Association and of Insurance Commissioners
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Association of state insurance regulatory problems and in formaing recomending model legislation amd requirements
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natural group
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a group formed for a reason other than to obtain insurance
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needs approach
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a method for determing how much insurance protection a person should have by analzing a family's or business's needs and objecties should the insured die, become disabled or retire
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non admitted insurer
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an insurance company that has not be licensed to operate within a given state
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non cancelable and guranteed renewable contract
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Health insurance contract that the insured has the right to continue in force by payment of premiums set forth in the contract for a substantial period of tme, during which the insurer has no right to make unilaterally any changes in any contract provision
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non contributory plan
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Employee benefit plan under which teh employer bears the full cost of the employees benefits; must insure 100 percent of eligible employees
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non disabling injury
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requires medical care, but does not result in loss of time from work
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nonmedical insurance
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issued on a regular basis without regulater medical examiniations In passing on the risk; the company relies on applicants answers to quions regarding his or her physical condition and on personal referenece or inspection reports
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Offer and Acceptance
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The offer may be made by the applicant by signing the application paying the first premium and if necessary submiting to a physical examination. Policy issuance, ias applied for, constitutes acceptance by the company. Or the offer may be madye by the company when no premium payment is submitted with application. Premium payment on the offered policy then constitutes acceptance by teh applicant
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Old Age Survivors Disability and Hospital Insurance (OASDI)
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Retirement deathh, disability income and hospital insurance benefits provided under the Social Security System
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open panel HMO
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a network of physicians who work out of their own office and participate in the HMO on a part-time basis
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optionally renewable contract
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Health or in insurance policy whihc the insurer reserves the right to terminate the coverage at any anniversary or in some cases at premium dud date, but does not have the right to terminate covergae between such dates
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overhead insurance
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type of short term disability insurance reimburing the insured for specified, fixed montly expenses, normal and customary in operatin the insured's business
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own occupation
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a definiton of total disability that requires that in order to receive disability income benefits the insured must be unable to work at his or her own occupation
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parol evidence rule
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rule or contract law that brings all verbal statements into written contract and disallows any changes or modification to the contract by oral evidence
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estoppel
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legal impediment to denying the consequences of one's actions or deeds if they lead to detrimental actions by another
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evidence of insurability
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amu statement or proof regarding a person's physical condition occupation and so forth affecting acceptance of the applicant for insurance
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exclusion rider
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Health insruance policy rider that waives insurer's liabilitgy for all future claims on a preexisting condition
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exclusions
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specified hazards listed in a polidy for which benefits will not be paid
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exclusive provider organization
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a variation of the PPO concept an EPO contracts with an extremely limited number of physicians and typically only one hospital to provide services to members members who elect to get health care from outside the EPO receive no benefits.
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Fair Credit Reporting Act
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Federal law requiring an individual to be informed if he or she is being investigated by an inspection company
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Florida Comprehensive Health Association
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Gurantees health insurance to Florida residents who cannot get coverage because of poor health, at rates up to 250 percent of standard rates. All health insurers, service organizations and fraternal benefit societies selling health insurance must belong to the association
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Florida Employee Health Care Access Act
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State law governing provisions of group health insurance provided by insurers or HMOs to small employers
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Florida Health Insurance Coverage Continuation Act
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Legislation that requires insurers selling health plans to small employers to offer a right to elect continued coverage, without providing eveident of insurability to the covered employees or their dependents who iwll lose employer sponsored group coverage and who is unable to obtain replacement insurance
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Florida Viatical Settlement Act
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State law that provides for regulation of viatical settlement contracts and providers by the Department of Insurance
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franchise insurance
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life or health insruance plan for covering groups of persons wiht individual policies uniform in provisions, although perhaps different in benefits Solicitation usually takes place in an employer's business with the employer's consent. Generally written for groups too small to qualify for regular group coverage. May be called wholesale insurance when the policy is life insurance
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fraternal benefit insurer
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Nonprofit benevolent organization that provides insurance to its members
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free look
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provision required in most states whereby policy holders have either 10 or 20 days to examine their new policies at no obligation
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grace period
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period of time after the due date of a premium during which the policy remains in force without penalty
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guaranteed insurability
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Arrangement usually provided by rider, whereby additional insurance may be purchased at various times without evidence of insurability
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Health maintenance organization
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Health care management stressing preventive health care, early diagnois and treatment on an outpatient basis. Persons generally enroll voluntarily by paying a fixed fee periodically
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Home health care
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skilled or unskilled care provided in an individual's home, usually on a part time basis.
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home service insurer
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insurer that offers relatively small policies with premium payable on a weekly basis, collected by agents at the policyowner's home
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hospital benefits
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payable for charges incurred while the insured is confined to or treated in a hospital as defined in a health insurance policy
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hospital expense insurance
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health insurance benefits subject to a specified daily maximum for a specified period of time while the injured is confined to a hospital, plus a limited allowance up to a specified amount for miscellaneous hospital expenses, such as operating room, anethesia, laboratory fees, and so on. Also called hospitalization insurance
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hospital indemnity
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form of health insurandce providing a stipulated daily, weekly or monthly indemnity during hospital confinement payalbe on an unallocated basis without regard to actual hospital expense
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industrial insurance
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life insurance policy providing modest benefits and a relatiely short benefit period. Premiums are collected on a weekly basis by an agent calling at insured's home
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insurability
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all conditions pertaining to individuals that affet their health, susceptibility to injury, or life expectancy an individual's risk profile
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insurability receipt
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a type of conditional receipt that makes coverage effective on the date the application was signed or the date of the medical exam which ever is later provided that the applicant proves to be insurable
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insurable interest
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requirement of insurance contracts that loss must be sustained by the applicant upon the death or disability of another and loss must be sufficent to warrant compensation
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insurance
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social device for minimizing risk of uncertainty regarding loss by speading the risk over a large enough number of similar exposures to predict the individual chance of loss
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insurance code
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the law that governs the business of insurance in a given state
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insurer
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is the party that provide insurance coverage typically through a contract of insurance
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insuring clause
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defines and describes the scope of the coverage provided and limits of indemnification
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intermediate nursing care
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level of health or medical care that is occasional or rehabilitative ordered by a physician and performed by skilled personnel
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Old Age Survivors Disability and Hospital Insuracne
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Retirement death disability income and hospital insurance benefits provided under the Social Security System
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Natural Group
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A group that was formed for some other reason other than to obtain insurance. Qualifying groups include employers labor unions trade associations creditor debtor groups, multiple employer trusts, lodges and the like
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Dental Care
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deductible and coinsurance features are typical though some policies will cover routine cleaning and exams at 100 percent as are maximum yearly benefit amounts sucha s $1,000 or $2,000
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Vision care
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coverage usually pays for reasonbale cand customary charges incurred during eye exams by opthalmologists and optometrists. Expenses for the fitting or cost of contact lenses or eyeglasses ofter are exlclude
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Coordination of Benefits
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it is to avoid duplication of benefit payments and overinsurance when an individula is covered under more than one group health plan
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Maternity Benefits Group plans
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medical expense plands must provide maternity benefits. This is the result of the 1979 amendment to the Civil Rights Act, which requires plans covering 15 or more people to treat pregnancy related claims no differently than any other allowable medical expense.
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Group short term disability plans
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are characterised by maximum benefit periods of rather short duration 13 to 26 weeks. Benefits are typically paid weekly and range fromm 50 to 100 percent of the individual's income.
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Group long term disability plans
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provide maximum benefitsw of more than two years, occasionaly extending to the insured's retirement age. Benefits amounts are usually limited to about 60 percent of the participants income
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If an agent knows the client did not put in an application certain information about an illness that the client sustained, what should the agent do?
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Advise the client he may not have a valid claim later on
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Which of the following benefits can be incuded in a group health plan?
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Medical insurance, disability insurance, and accidental death and dismemberment insurance
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Mr. Finklestein has an accident and goes on disability income. After 9 months, he goes back to work. After 3 more months he finds he returned to work too soon and must go back on disability. How will teh company handle the claim.
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It will be considered a continuation of the same disability
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An HMO fouind guilty of unfair trade practices act could be charged a penalty
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up to $50,000 and if the violation is criminal, it can result in imprisonment
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Must a health company return unearned premium on a cancelled policy
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yes
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Washington takes a skiing trip and breaks a leg. Upon returning home, he purchases a major medical policy and files a claim which the company disapproves. The reason they decline the claim is
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a preexisting condition
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HMOs are known for stressing preventive care, with their subscribers paying a fixed periodic fee in advance.
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True
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Randall has a major medical policy with a flat $500 deductible and an 80/20 co-insurance with a stop loss of $2000.
What would Randall's total out of pocket expense be if he was to go to the hospital and was charged $25000 for medical expenses his surgeon charged $10,500 and he had not yet met his deductible? |
$2000
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Premiums for industrial policies are somewhat higher thatn ordinary policies that have the sames face amount.
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False
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In health policy, an individual has how may days in which to file proof of loss on the forms provided by company
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90 days
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Which policies are required to coordinate benefits?
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Group policies
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In a disability policy, what factor when increased causes a decrease in benefit?
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Morbidity
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Under a typical HMO plan, each member pays:
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a fixed premium whether or not he/she uses the health plan.
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A business overhead expense policy includes all of the following except
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employers income
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Which of the following is true about Medicare?
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It has two parts: Part A and Part B
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A cafeteria plan is a benefit arrangemetn which
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allows employees to tailor theri benefit package to meet their specific needs
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When does the blackout period begin?
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When the youngest child turns 16.
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Under social security, when does the black out period begin for a surving spounse?
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If there are no children the black out period begins immediately and continues until at the earliest the spouse reaches age 60
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Preexisting conditions are referred to in which of the following health policy areas?
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Insuring clause?
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The agen has just been told by a policyowner taht she is 4 years younger tahtn what whe was listed on the application. The agent should
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notify the insurance company to adust existing policy to teh correct age.
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When a company selects a non insurance company to administer their self insured plan the company is called
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TPA-Third Party Administrator
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In Medicare supplement policies the free lok provision
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extended to 30 days
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Which of the following is included in an Outline of Coverage?
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a brief description of the benefits and coverage; a summary of the renewals and cancelation provisions and a summary of exlusions
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Under individual and group health insurance sold in Florida coverage for a newborn child of the insured begins how soon after birth
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immediately
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Premiums for industrial health policies are
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low because there is not much protection?
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On a reinstated health policy how long after the policy is reinstated will coverage for sickness become effective?
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10 days
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What are the categories of health care policies
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medical expense, accidental death, disability income
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Medical expense is considered what type of contract?
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reimbursement contract page 265
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Disability income and AD & D are considered what type of contract?
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Valued contract page 265
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partial disability
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illness or injury preventing insured from performing at least one or more but not all of their occupational duties
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A chef who is receiving disability Income benefits is unable to return to work full time but continues his occupation on a part time basis.
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A Partial Disability Benefit Clause ( pp. 293-294)
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What is a cancellable policy?
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A policy the insurer may cancel at any time by returning hte unearned premium page 329
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The Health Maintenance Organiation concept that servie providers are paid a fixed monthly fee for each member
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closed panel page 525
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Medicaid is described as
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medical benefis for certain low income people for the disabled and for familie sof dependant children
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Blue Cross and Blue Shield
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is a voluntary not for profit organization, Blue cross is designed to cover hopital expenses and blue shield is designed to cover physician/doctors expenses page 268
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HMOs
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Stree preventive care, rarely access deductibles, and provide coverage for routine doctors visits and hospital care pp. 268-269
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If an agent accepts a premium for a lapsed disability policy coverage for accidents becomes effective in how many days after the acceptance of the premium?
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coverage is immediate page 295
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Open Panel HMO
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A network of physicians who work out of their own offices and participate in the HMO on a partime basis.
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What is the mimimum grace period, provided in the required Provision 3 for all policies other than monthly or weekly premium policies
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31 days page 326
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