Making Sense of It All
Health Insurance Terms
A | B | C | D | E | F | G | H | I | J |
K | L | M | N | O | P | Q | R | S |
T | U | V | W | X | Y | Z
Actuary
A professional trained in the mathematics of insurance and risk management.
Add-ons
Additional coverage to your basic policy.
Agents
Two types of agents sell insurance: Independent agents are self employed business people who typically represent two insurance companies and are paid on a commission basis. (Pedersen Associates is an independent agency; our brokers don't work for an insurance company.) Exclusive agents represent only one insurance company and may be salaried employees or work on a commission basis.
Alien Insurance company
An insurance company incorporated under the laws of a foreign country.
Application
A signed statement by a prospective insured person which becomes part of the health insurance contract.
~B~
Binder
Temporary insurance contract providing coverage until a permanent policy is issued.
Blanket Policy
A health insurance contract which protects all members of a certain group against a specific hazard.
Broker
A sales and service representative who handles insurance for clients, generally selling insurance of various kinds and for several companies.
~C~
Cancelable Policy
A policy which may be terminated by the company or the insured by proper notification sent to the other party according to the terms set forth in the policy.
Carrier
An insurer or insurance company.
Claim
(1) A formal request for payment of a loss under an insurance contract or bond. (2) The actual amount of the final settlement.
Claimant
One who seeks reimbursement for loss under the terms and conditions of his/her insurance contract.
Clause
A section or paragraph in an insurance policy that explains, defines or clarifies the conditions of coverage.
COBRA (Consolidated Omnibus Budget Reconciliation Act).
A federal law under which group health plans sponsored by employers with 20 or more employees must offer continuation of coverage to employees who leave their jobs, voluntarily or otherwise, and their dependents; gives individuals and their dependent family members the right to continue their health care coverage for as long as 18 months.
Coinsurance
In property insurance, a coinsurance clause requires the policyholder to carry insurance equal to a specified percentage of the value of the property in order to receive full payment of a loss. In health insurance, coinsurance is a percentage of each claim, above the deductible, that is paid by the policyholder.
Comprehensive Major Medical Insurance
A policy designed to give the protection offered by both a basic and major medical health insurance policy. It is characterized by a low "deductible" amount, coinsurance feature, and high maximum benefits - usually $5,000 to $10,000 or higher.
Conversion Privilege
A right granted to group certificate holders, by which they may obtain an individual policy (upon leaving the group) regardless of physical condition.
Co-payment
The portion, either a percentage or a fixed dollar amount, of a medical bill that a patient pays. The insurer pays the rest.
Coverage
A term usually referring to the type and extent of benefits provided by an insurance contract.
~D~
Declaration Page
That page of the insurance policy which lists the insurance company, its address, name of the policyholder, starting and ending dates of coverage, and the actual coverages given in the contract, including the locations and amounts.
Deductible
The amount of loss paid by the policyholder before the insurance policy benefits become payable.
Domestic Insurance Company
An insurer domiciled in this state.
~E~
Earned Premium
That part of the premium applicable to the expired part of the policy period, including the short-rate charge on cancellation.
Effective Date
The date on which an insurance policy coverage starts.
Employee Retirement Income Security Act of 1974 (ERISA)
Federal law that established rules and regulations to govern private pension plans. Most self-insured health plans are created under this act.
Evidence of Insurability
Any statement or proof of a person's physical condition, occupation, etc., affecting his acceptance for insurance.
Exclusions
Specified hazards for which a policy will not provide benefit payments. They are often called exceptions.
Experience
The record of claims made or paid within a specified time period.
Experience Rating
Determination of the premium rate for an individual risk, made partially or wholly on the basis of that risk's own past claim experience.
~F~
Fee for Service
The traditional model for health insurance, in which patients go to the doctor or hospital of their choice and the insurer pays the largest portion of the bill.
Flat Cancellation
Cancellation of an insurance policy as of the date of its start with no premium charge.
Foreign Insurance Company
An insurer domiciled in another state.
~G~
Guaranteed Renewable Policy
A policy which the insured has the right to continue in force by the timely payment of premiums to a specified age, (usually age 50) during which period the insurer has no right to make unilaterally any change in any provision of the policy while the policy is in force but may make changes in premium rates for the entire policyholder classification.
Guarantee Funds
All 50 states, the District of Columbia and Puerto Rico require licensed insurers to assume some of an insolvent insurance company's policyholder liabilities. These funds (life & health and property & casualty) are the mechanism by which solvent insurers bail out the policyholders of companies that fail.
~H~
Health Insurance
Protection against the costs of hospital and medical care or lost income arising from an illness or injury. Sometimes called Accident of Sickness Insurance, Accident and Health Insurance, or Disability Insurance.
Health Maintenance Organization (HMO)
An organization that provides health care for a monthly payment set in advance. In a traditional HMO, doctors and other providers are salaried employees and the facilities are owned by the organization. In recent years, however, other forms of HMOs have sprung up that contract with doctors and hospitals to care for members at set, negotiated fees. Many HMOs are hybrids, offering both kinds of care to members.
~I~
Insurance
A system to protect persons against the risks of financial loss by transferring the risks to a large group who share the financial losses.
Insurer
The company offering protection through the sale of an insurance policy to an insured.
Insured
The person whose risk is transferred and shared.
~L~
Long Term Care Insurance
Covers the cost of long-term custodial care in a nursing facility or at home.
Loss of Use Insurance
Insurance against loss due to the insured's inability to use property, such as a vehicle or a store; includes additional living expense, business interruption, rent insurance, rental reimbursement, and rental value.
~M~
Managed Care
span >A health plan that places limits on which treatments and which doctors, hospitals and other providers a member can use and still receive full coverage. Generally under managed care an insurer negotiates lower fees with doctors, hospitals, laboratories, for instance, who join in a network that members of the plan are encouraged to use. Frequently, members of a managed care plan can use health care providers outside the network, but they must pay a greater share of the cost.
Malpractice Insurance
A professional liability coverage that insures physicians, lawyers and other specialists against suits alleging their negligence.
Medicaid
A federal-state program that helps pay for health care for the needy, blind and disabled and for low-income families with children.
Medicare
A federal health care insurance program for people age 65 and over, and for the disabled.
Medigap
Because Medicare does not cover all expenses, private insurers sell "Medigap" policies to supplement federal insurance benefits.
~N~
No Fault
A system in which each driver's auto insurance coverage pays for injuries and damage, no matter who caused the accident.
cancelable or cancelable and Guaranteed Renewable Policy
A policy which the insured has the right to continue in force by the timely payment of premiums set forth in the policy to a specified age, (usually age 50) during which period the insurer has no right to make unilaterally any change in any provision of the policy while the policy is in force.
~P~
Paid-up Insurance
Life insurance policy under which all premiums have already been paid, with no further premiums due.
Pre-existing Conditions
A physical condition of an insured person which existed prior to the issuance of the policy.
Premium
The payment for an insurance policy, usually paid periodically, i.e., annually, semi-annually, quarterly or monthly.
Pro-rata
Cancellation of an insurance contract by the insurance company, allowing the policyholder a share of the premium relating to the remainder of the time under the contract that bears to the total contract premium.
~R~
Rebate
A reduction of a premium.
Reinsurance
A form of insurance that insurance companies buy for their own protection.
Rider
An endorsement to an insurance policy that modifies clauses and provisions of the policy, adding or excluding. coverage.
Risk
A term used to designate an insured or a peril insured against.
~S~
Short Rate
Cancellation of an insurance contract at the request of the policyholder with a refund of premiums to the policyholder of less than would be given under pro-rata consideration.
Specified Disease Insurance
A policy which provides stated benefits, usually of large amounts, toward the expense of the treatment of the disease or diseases named in the policy.
Solvency
One of MIA's primary responsibilities is to make sure insurance companies remain solvent, i.e., have sufficient assets and income, in order to have the ability to pay the claims of their policyholders.
~U~
Underwriting
Process of examining, accepting, or rejecting insurance risks, and classifying those selected, in order to charge the proper premium for each.
