HEALTH 1
Illness or injury preventing insured from performing at least one or more, but not all, of the insured's occupational duties.
partial disability
Health insurance that provides coverage to fill the gapsin Medicare coverage.
Medicare supplement policy
A definition of total disability. The insured must be unable to perform any job for which he is "reasonably suted by reason of education, training or experience." It is more difficult for the insured to collect benefits under this definition.
any occupation
Requires medical care, but doe snot result in loss of time from work.
nondisabling injury
Termination of a policy upon the policy owner's failure to pay the premium by the end of the grace period.
lapse
A statement believed to be true to the best of one's knowledge.
representation
A broad description of insurance to offset the cost of accident or illness. May be in the form of reimbursement of indemnity (cash) policies.
health insurance
An insurer that is incorporated, organized, or domiciled in this state.
domestic insurer
The specific authority given in writing to the agent in the contract of agency.
express authority
Insurance premium will always be unequal to the benefits received. Benefits will usually be larger than the premium.
aleatory
This provision's found in health insurance stating if the insured changes to a more hazardous occupation, benefits are reduced; if changing to a les hazardous occupation, premiums are reduced.
change of occupation provision
A mandatory NAIC provision stating that the insured must submit a completed claim form with documentation of loss to the insurer within 90 days of the date loss.
proof of loss
Protection of a business against financial loss caused by the death or disability of a vital member of the company.
key-person insurance
If a businessowner becomes disabled, this policy will not replace the owner's income, but will instead help pay the expenses of operating the business such as rent, utilities, and wages.
business overhead expense insurance
Federally sponsored health insurance and medical program for persons age 65 or older, or who have been receiving Social Security disability for the past 24 months, or who have permanent kidney failure.
Medicare
An organization or program that seeks to control costs through utilization review and other methods.
managed care organization
A network of physicians who work out of their own offices and participate in the HMO on a part-time basis.
open-panel HMO
Group insurance plan issued to an employer under which both the employer and the employees contribute to the cost of the plan. Generally, 75% of the eligible employees must be insured.
contributory plan
The reason for the loss (fire, wind, hail, and so forth).
peril
A consumer reporting agency that operates a database of medical information on individuals who have previously applied for life and health insurance. Member issuers can access this data with the consent of an applicant.
Medical Information Bureau (MIB)
Provides for the monthly payment of a portion of the insured's income should the insured become disabled.
disability income insurance
Health insurance policy that provides first dollar coverage for specified (and limited) health care, such as hospitalization, surgery, or physician services. Characterized by limited benefit periods and relatively low coverage limits.
basic medical expense policy
While not totally disabled, the policy will pay the insured a portion of his lost income if he is not able to work as much or is forced to work at a job that pays less.
residual disability benefit
Refers to the broad range of medical and personal services for individuals (often the elderly) who need assistance with daily activities for an extended period of time for chronic illnesses like arthritis, rheumatism, and so forth.
long-term care
Medical care leading to recovery which is received on a daily basis.
skilled nursing home
Information consumer guide books that explain insurance policies and insurance concepts; in many states, they are required to be given to applicants when certain types of coverage are being considered.
buyer's guides
Coverage for hospital room and board as well as other expenses. Often subject to daily and maximum limits.
hospital expense insurance
Charge for health care service consistent with the going rate of charge in a givin geographical area for identical or similar services.
reasonable and customary charge
Medical care leading to recovery which is received on an occasional basis as opposed to intense, daily care.
intermediate nursing care
The four ways risks are classified.
preferred, standard, substandard, or decline
The applicant must be sane, sober, and of legal age to enter a contract.
competent parties
The insurer excludes a specified preexisting condition.
exclusion rider
Health or medical care designed to help an individual perform the activities of a daily living. Coverage for this type of care is only provided by long-term care insurance.
custodial care
Regardless if the insured is able to work, he is eligible or full disability benefits if he has complete loss of speech, hearing, vision of the loss of use of two or more limbs.
presumptive disability benefit
Type of health or medical care designed to provide a short rest period for a caregiver.
respite care
Selection against the company. Tendency of less favorable insurance risks to seek or continue insurance toa greater extent than others. Also, tendency of policyowners to take advantage of favorable options in insurance contracts.
adverse selection
Extends group health coverage to an employee who loses her job for reasons other than gross misconduct. Coverage may also be extended for family members who lose coverage for various reasons such as death or divorce.
COBRA
Health care management stressing preventive health care, early diagnosis, and treatment on an outpatient basis. Persons generally enroll voluntarily by paying a fixed fee periodically.
health maintenance organization (HMO)
An act of deceit; concealment or misrepresentation of a material fact.
fraud
A period of time between the issuance of a policy and the date coverage begins (sickness is not covered during this time).
probationary period
Found within the insurance policy representing the insurer's promise to pay under the conditions found in the policy names the parties to the contract and describes the general scope of coverage.
Hospitalization insurance that provides specified in-hospital and related benefits. Hospital admissions are subject to a deductible and possible co-pays.
Medicare Part A
Pays on the basis of what is considered usual, customary, and reasonable (UCR) in a certain geographic area and based on amount physicians in area usually charge for same or similar procedures.
nonscheduled plan
The insurer and insured share any expenses above the deductible amount. This is applied after the insured has satisified his deductible requirement.
coinsurance
This element of a contract is either made by the applicant (when an application is completed and premium is submitted) or is made by the insurance company (when no premium is submitted with application).
offer