Lifeexam-Ch8

Front 1

peril

Back 1

specific CAUSE of a loss

Front 2

preexisting condition

Back 2

prior med condition for which app has recived or should have recived med advice/treament within a specfiec period before the effective date

Front 3

probatyionary period

Back 3

time before new coverage goes into effect for specified conditions (preexisting conditions)

Front 4

waiting period

Back 4

time set by employer before employee elgiible to enroll for group benefits

Front 5

subrogation

Back 5

when insurer seeks recovery of amount paid to the insured form 3rd party responsible for loss.

Front 6

loss of income/disability

Back 6

pays weekly or monthly. percentage of past earnings

Front 7

medical expenses(5)

Back 7

various expenes
1. blanket-maximum overall
2. scheduled - benefits in amount listed
3. cash - lumps sum for max 3 of days
4. reimubursment-pays to insured
5. fee for service-paid directly to provider for med services
6. prepaid-coordinates health care for montly premiums

Front 8

accidental death/dismemberment

Back 8

1. principal amount upon death.loss of sight or 2 limbs
2. smaller amount for less dismemberment

Front 9

field underwriting imporance

Back 9

due to the risk of moral hazard. determine if group has same probability of loss

Front 10

net insurance rates

Back 10

frequency of claim * average value of claim

Front 11

other underwriting factos

Back 11

everything about person or group and geogrpahical area. NOT policital or religious demographics

Front 12

4 underwriting actions

Back 12

1. issue standared-at quoted
2. " rated up - higher rate(like substandard life)
3. " w/ exclusions/limitation - temp or permanent; limits insurers obligation to pay
4. rejection - policy NOT issued

Front 13

groups - geogrpahical for states

Back 13

also look at state where majoirty of employees are NOT where corporate office is. Higher ther average age = higher the insurance

Front 14

groups - 5 ways to reduce adverse selection

Back 14

1. formed for other than getting cheap insurance
2. minimum enrolles
3. contributory plans state employer and employee contrib with 75% participation
4. noncontributory employer pay all but 100% participation
5. employees ahve to work mimim work wee to be eligible

Front 15

groups - community vs. experience rated

Back 15

1. community - geogrpahical rateing
2. experience - claims history of group

Front 16

5 group plan design factors

Back 16

1. employers objectives- will vary
2. types of benefits-ongoing decesion
3. provisio for controlling cost-probation periods, benefit limitations
4. benefit communication -comm program
5. benefit outsourcing - otusource benefit administration

Front 17

goup provisions - who gets what

Back 17

group sponsor gets master policy adn employees get certificate of insurance...all ahve same coverage.

Front 18

group provisions - conversion privilage

Back 18

employee to convert to individual policy WITHOUT proof of insurability upon term of eligibility or group plan submitted within 31 days

Front 19

groups - extension of benefits

Back 19

if med expense policy terminated the benefits to disabled extended for 3 months adn 12 months for major medical

Front 20

coordination of benefits

Back 20

spouse becomes secondary. whoever birthday is first

Front 21

eligible grups - employment related

Back 21

1. reg
2. METs
3. MEWAs- formred to get cheap insurance
4. unions MUST go through trust

Front 22

eligible groups - associations

Back 22

mimimum member (100) other than purpose for cheap insuarnce. underwriting hard if no claim history

Front 23

eligible grups - customer groups

Back 23

depositior, creditor/debtor

Front 24

eligible gruops- franchise (wholesale)

Back 24

small employers who dont have enough employees for group

Front 25

replacing group policy

Back 25

ALWAYS provide comparision of benfits
1. replacing hospital, med, or surgical cover for 60 days
2. proabition period could be used in place of excluding outright preexsisting conditon
3. no loss-no gain- ongoing claims forms must continue also hold-harmless agreement

Front 26

small employer definiton

Back 26

1. business group of one-stan
2. small employer-
3. eligible employee-regular work week
4. must offer to all eligble employees

Front 27

small emploloyer-essential (basic) adn standard benefit plan

Back 27

employer MUST offer atleast 2 health benefit plans.
1. essential- basic
2. standard
both must have materinity benefits

Front 28

small employer-rating factor

Back 28

consistnent will all small employers. premiums will be different from other grups by plan design not by groups themselves. preexising conditions excluded longer than 1 year

Front 29

small employer - renewability of coverage

Back 29

renewable except at option of exployer excpet when
1. nonpayment of premium
2. fraud
3. noncompliance
4. insufficent # of people
5. INSURERE CANNOT cancel for frequency of claims

Front 30

worksite plans

Back 30

voluntary salary reduciton plan & employees pick and choose and ARE PORTABLE TO EMPLOYEE. these are flexible in payment (employer only, employee only) and can be used to complement other plans